D
MedPAC Data Runs
As requested in its congressional mandate, the committee consulted with the Medicare Payment Advisory Committee (MedPAC) in its examination of pay for performance. Specifically, MedPAC was requested by the committee to perform some limited data runs on payments associated with the treatment of three clinical conditions: coronary artery disease, chronic heart failure, and diabetes. The following tables represent data submitted to the committee by MedPAC and include breakdowns of payments by condition, as well as aggregations for those beneficiaries who were treated for more than one of the three conditions. Additionally, the data include the number of unique physician identification numbers (UPINs) submitting claims per beneficiary, as well as the types of claims (evaluation and management, major surgery, other surgery, testing, and imaging).
These data were generated from the Medicare 5 percent Standard Analytic Files for 2003 (inpatient, outpatient, and physician/supplier). Beneficiaries living in the U.S. territories are not counted in this analysis, but beneficiaries under the age of 65 and those with claims from managed care and hospice care, decedents, and new entrants are included.
These data helped inform the committee as to the nature of the care being delivered to Medicare beneficiaries and the payments associated with this care. The committee used the data to derive conclusions regarding the attribution of care and the magnitude of potential reward levels.
TABLE D-1 Number of Beneficiaries and Payments for Beneficiaries in Groups A–G
TABLE D-2 Number of Physician Providers per Beneficiary in Groups A–G
(d) |
(e) |
(f) |
(g) |
(h) |
Maximum Number of Physician UPINs per Beneficiary |
Standard Deviation Number of Physician UPINs per Beneficiary |
Total Number of Beneficiaries |
Total Number of UPINs |
Total Number of UPINs Related to Condition |
44 |
8 |
33,156 |
174,016 |
100,639 |
38 |
7 |
45,669 |
190,398 |
85,129 |
36 |
7 |
20,084 |
116,830 |
54,526 |
29 |
5 |
52,831 |
187,777 |
93,058 |
30 |
6 |
44,624 |
171,838 |
55,812 |
24 |
4 |
139,998 |
262,774 |
89,953 |
21 |
4 |
183,021 |
285,479 |
135,033 |
16 |
3 |
1,108,039 |
389,895 |
|
30 |
5 |
519,383 |
363,096 |
212,855 |
23 |
4 |
1,627,422 |
406,984 |
|
TABLE D-3 Proportion of Beneficiaries with 1–10+ Physicians Billing for Care
TABLE D-4 Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider
TABLE D-5 Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider for the Condition
TABLE D-6 Proportion of Beneficiaries Associated with a Percent of Physician Provider Claims Allocated to One Provider
TABLE D-7 Proportion of Beneficiaries Associated with a Percent of Physician Provider Claims Allocated to One Provider for the Condition
|
(a) |
(b) |
(c) |
(d) |
(e) |
(f) |
Group |
Total Beneficiaries w/ Physician Providers |
70–100% of Claims to Provider |
50–69% of Claims to Provider |
35–49% of Claims to Provider |
20–34% of Claims to Provider |
0–19% of Claims to Provider |
A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease |
32,225 |
18.30% |
27.43% |
22.56% |
26.33% |
5.38% |
B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes |
43,652 |
29.84% |
29.84% |
16.79% |
20.61% |
2.93% |
C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease |
19,173 |
41.46% |
29.30% |
13.73% |
13.86% |
1.65% |
D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure |
50,844 |
34.28% |
34.82% |
16.74% |
13.13% |
1.04% |
E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease |
38,728 |
59.70% |
24.09% |
5.29% |
10.08% |
0.84% |
F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure |
128,289 |
54.73% |
30.54% |
6.50% |
7.77% |
0.46% |
TABLE D-8 Payments by Type of Service for Beneficiaries Within Groups
|
(a) |
(b) |
Group |
Evaluation & Management— Payment ($) |
Evaluation & Management— Percent |
A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease |
86,471,514 |
45% |
B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes |
91,924,988 |
45% |
C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease |
36,190,515 |
47% |
D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure |
64,463,785 |
36% |
E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease |
60,720,321 |
45% |
F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure |
130,330,105 |
34% |
G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease |
132,909,072 |
37% |
X—No Condition Category Assigned |
500,560,122 |
34% |
Total in Groups |
603,010,300 |
39% |
Total in File |
1,103,570,422 |
37% |
(c) |
(d) |
(e) |
(f) |
(g) |
(h) |
Major Procedure— Payment ($) |
Major Procedure— Percent |
Other Procedure— Payment ($) |
Other Procedure— Percent |
Testing— Payment ($) |
Testing Percent |
19,163,429 |
10% |
25,373,801 |
13% |
12,051,707 |
6% |
21,282,956 |
10% |
24,885,905 |
12% |
12,995,751 |
6% |
4,853,795 |
6% |
11,645,941 |
15% |
5,219,937 |
7% |
19,128,346 |
11% |
32,277,301 |
18% |
15,187,808 |
8% |
8,747,398 |
7% |
18,423,696 |
14% |
8,624,945 |
6% |
40,659,972 |
10% |
70,003,113 |
18% |
30,908,776 |
8% |
18,909,673 |
5% |
79,599,074 |
22% |
32,043,053 |
9% |
78,532,780 |
5% |
355,184,517 |
24% |
114,339,344 |
8% |
132,745,569 |
9% |
262,208,831 |
17% |
117,031,976 |
8% |
211,278,349 |
7% |
617,393,349 |
20% |
231,371,321 |
8% |
(l) |
(m) |
(n) |
(o) |
(p) |
(q) |
Durable Medical Equipment— Percent |
Other— Payment ($) |
Other— Percent |
Exceptions and Unclassified— Payment ($) |
Exceptions and Unclassified— Percent |
Total Payments ($) |
0% |
28,039,940 |
15% |
817,439 |
0% |
190,763,249 |
0% |
29,533,420 |
14% |
882,031 |
0% |
204,803,139 |
0% |
12,380,993 |
16% |
418,372 |
1% |
77,771,058 |
0% |
22,594,208 |
13% |
667,568 |
0% |
180,745,584 |
0% |
22,479,758 |
17% |
845,928 |
1% |
133,677,894 |
0% |
49,551,807 |
13% |
1,454,542 |
0% |
388,080,620 |
0% |
54,017,297 |
15% |
1,660,703 |
0% |
358,203,919 |
0% |
241,534,417 |
16% |
7,624,558 |
1% |
1,484,938,240 |
0% |
218,597,423 |
14% |
6,746,583 |
0% |
1,534,045,463 |
0% |
460,131,841 |
15% |
14,371,140 |
0% |
3,018,983,703 |
TABLE D-9 Average Parts A & B Enrollment by Beneficiary Designation
TABLE D-10 Preventive Services
TABLE D-11 Vaccine Payments
TABLE D-12 Evaluation and Management Claims—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care
TABLE D-13 Evaluation and Management Claims—Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider
TABLE D-14 Evaluation and Management Claims for Beneficiaries with Hospitalization—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care
TABLE D-15 Evaluation and Management Claims for Beneficiaries with Hospitalization—Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider
TABLE D-16 Evaluation and Management Claims for Beneficiaries without Hospitalization—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care
TABLE D-17 Evaluation and Management Claims for Beneficiaries without Hospitalization—Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider
TABLE D-18 Evaluation and Management Claims Excluding Place of Service 21—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care
TABLE D-19 Evaluation and Management Claims Excluding Place of Service 21—Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider
TABLE D-20 Evaluation and Management Claims for Beneficiaries with Hospitalization Excluding Place of Service 21—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care
TABLE D-21 Evaluation and Management Claims for Beneficiaries with Hospitalization Excluding Place of Service 21—Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider
TABLE D-22 Evaluationand Management Claims for Beneficiaries without Hospitalization Excluding Place of Service 21—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care
TABLE D-23 Evaluation and Management Claims for Beneficiaries without Hospitalization Excluding Place of Service 21—Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider
TABLE D-24 Evaluation and Management Claims—Percent of Beneficiaries Seeing Five or Fewer Physicians
|
E&M Claims |
E&M Claims with Hospitalization |
E&M Claims without Hospitalization |
E&M Claims: Outpatient Care Only |
E&M Claims: Outpatient Care with Hospitalization |
E&M Claims: Outpatient Care without Hospitalization |
Total in File |
75.42% |
35.44% |
88.09% |
81.46% |
59.15% |
88.85% |
Total in Groups |
58.79% |
29.86% |
81.54% |
70.55% |
55.30% |
82.44% |
TABLE D-25 Evaluation and Management Claims—Percent of Payments Made to 35 Percent or More Providers
|
E&M Claims |
E&M Claims with Hospitalization |
E&M Claims without Hospitalization |
E&M Claims: Outpatient Care Only |
E&M Claims: Outpatient Care with Hospitalization |
E&M Claims: Outpatient Care without Hospitalization |
Total in File |
76.33% |
57.03% |
82.38% |
79.12% |
68.01% |
82.86% |
Total in Groups |
70.48% |
53.51% |
83.77% |
76.20% |
65.73% |
84.34% |
NOTE: Percent of beneficiaries not hospitalized for total in file = 76%; total in groups = 56% (see Table D-16). |