The trend across payers is to develop episodes of care for certain disease states, particularly when identifying high cost/high gaps in care among a patient population. This is part of what population health is all about.
Stedman’s Dictionary defines an episode of care as “all services provided to a patient with a medical problem within a specific period of time across a continuum of care in an integrated system.” There are a number of payment models that are based on the concept of the “episode,” but they lack the all-encompassing nature of this definition for any disease process. DRGs represent an episode of a hospital stay but do not include all services outside the confines of the hospital-based payment system. The current bundled payment models represent a more recent type of episode, but are still generally focused on a hospital-based event.
Challenges in Episode Development
Public and private methodologies used to define episodes that may be implemented in current and proposed alternative payment models face significant challenges that will need to be addressed in order to provide a solution that is meaningful to stakeholders and serves as a tool for understanding healthcare value. Addressing these challenges will require that certain requirements are met:
Definition of episodes. The definition of the episode must be clear and transparent to ensure that codes and other data parameters used to create the episode data are clinically meaningful.
Attribution. Data must be accurate, specific, and sufficiently complete to ensure that the right services, costs, persons, and providers are attributed to the intended episode instance and that data related to episodes is not over or under counted.
Risk adjustment. Risk adjustment should be sufficiently granular to ensure that the clinical and financial risks of the episode are appropriately considered.
Data quality. A clear understanding of the quality of reported data, including diagnostic and service codes, must be factored into the assumptions used in the application of episodes for analytic and payment purposes.
CentraState PHO Efforts
The CentraState PHO, under the direction of Robert Pedowitz, DO, and the Clinical Practice Committee, are developing episodes of care centering around three employee chronic issues identified with high cost/high gaps. These include diabetes, back pain, and obesity. Committees are meeting now to review and discuss these topics. We welcome your input—if you are interested in being involved, please contact us.
– James J. Matera DO, FACOI