ArticleMedicare & medicaid research review2013
Episode-based payment: evaluating the impact on chronic conditions.
Article in Medicare & medicaid research review, 2013. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 10 papers.
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Who cites it
10 citing papers in PubMed.
- Win-Win Pricing of Follow-Up Policies Under Healthcare Warranties for Chronic Diseases: A Mathematical Modeling Approach.Healthcare (Basel, Switzerland) · 2025Article
- Determining prescriptions in electronic healthcare record data: methods for development of standardized, reproducible drug codelists.JAMIA open · 2023Article
- Association of Mental Health Disorders With Health Care Utilization and Costs Among Adults With Chronic Disease.JAMA network open · 2019Article
- Impact of Incident Cancer on Short-Term Coronary Artery Disease-Related Healthcare Expenditures Among Medicare Beneficiaries.Journal of the National Comprehensive Cancer Network : JNCCN · 2019Article
- A practical guide to episode groupers for cost-of-illness analysis in health services research.SAGE open medicine · 2019Review
- The Generation of Integration: The Early Experience of Implementing Bundled Care in Ontario, Canada.The Milbank quarterly · 2018Article
- Implications of DRG Classification in a Bundled Payment Initiative for COPD.American journal of accountable care · 2017Article
- Design and impact of bundled payment for detox and follow-up care.Journal of substance abuse treatment · 2017Article
- When policy, demographics, and disease collide: the penalty of poor diabetes care in immigrant children.Pediatric research · 2016Article
- Estimating the costs of diabetes by episodes of care: promises and challenges.Journal of diabetes and its complicationsArticle
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Authors and funding
9 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundPolicy makers are interested in aggregating fee-for-service reimbursement into episode-based bundle payments, hoping it will lead to greater efficiency in the provision of care. The focus of bundled payment initiatives has been upon surgical or discrete procedures. Relatively little is known about calculating and implementing episode-based payments for chronic conditions.
objectiveCompare the differences in two different episode-creation algorithms for two common chronic conditions: diabetes and coronary artery disease (CAD). STUDY
designWe conducted a retrospective evaluation using enrollees with continuous coverage in a self-funded plan from 2003 to 2006, meeting Healthcare Effectiveness Data and Information Set (HEDIS) criteria for diabetes or CAD. For each condition, an annual episode-based payment was assessed using two algorithms: Episode Treatment Groups (ETGs) and the Prometheus model. PRINCIPAL
findingsWe began with 1,580 diabetes patients with a 4-year total payment mean of $67,280. ETGs identified 1,447 (92%) as having diabetes with 4-year episode-based mean payments of $12,731; while the Prometheus model identified 1,512 (96%) as having diabetes, but included only 1,195 of them in the Prometheus model with mean diabetes payments of $23,250. Beginning with 1,644 CAD patients with a 4-year total payment mean of $65,661, ETGs identified 983 patients (60%) with a 4-year episode-based mean of $24,362. The Prometheus model identified 1,135 (69%) as CAD patients with 948 CAD patients having a mean of $26,536.
conclusionsThe two episode-based methods identify different patients with these two chronic conditions. In addition, there are significant differences in the episode-based payment estimates for diabetes, but similar estimates for CAD. Implementing episode-based payments for chronic conditions is challenging, and thoughtful discussions are needed to determine appropriate payments.
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