National Academies Press: OpenBook

Rewarding Provider Performance: Aligning Incentives in Medicare (2007)

Chapter: Appendix D: MEDPAC Data Runs

« Previous: Appendix C: Comparison of Various Professional Groups' Pay-for-Performance Position Statements
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

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.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

TABLE D-1 Number of Beneficiaries and Payments for Beneficiaries in Groups A–G

 

(a)

(b)

(c)

(d)

(e)

Group

Number of Beneficiaries

Total Payments (Inpatient, Outpatient, and Carrier)

Total Physician Payments

Total Physician Fee Schedule Payments

Total Physician Fee Schedule Payments with Condition

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

33,156

$930,459,017.78

$190,763,248.74

$145,289,007.75

$63,478,717.18

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

45,669

$973,068,755.23

$204,803,139.36

$156,203,604.11

$51,811,091.99

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

20,084

$343,667,332.55

$77,771,058.17

$57,876,926.78

$17,685,633.11

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

52,831

$650,379,010.79

$180,745,583.66

$135,706,435.84

$49,925,585.96

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

44,624

$571,843,797.98

$133,677,894.22

$98,210,007.62

$15,564,360.34

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

139,998

$1,278,200,988.51

$388,080,620.15

$290,563,134.95

$73,437,377.10

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

183,021

$1,010,989,783.78

$358,203,918.84

$254,121,712.13

$58,724,822.67

X—No Condition Category Assigned

1,108,039

$3,659,514,615.32

$1,484,938,239.88

$1,038,689,792.23

 

Total in Groups

519,383

$5,758,608,686.62

$1,534,045,463.14

$1,137,970,829.18

$330,627,588.35

Total in File

1,627,422

$9,418,123,301.94

$3,018,983,703.02

$2,176,660,621.41

$330,627,588.35

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

(a) All beneficiaries with at least one claim line with a valid provider number.

(b) Payments from the inpatient, outpatient, and carrier file.

(c) Carrier file in total, regardless of provider type and fee schedule designation.

(d) Carrier file, only payments associated with the fee schedule.

(e) Carrier file, payments associated with the fee schedule for the condition associated with the disease group.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

TABLE D-2 Number of Physician Providers per Beneficiary in Groups A–G

 

(a)

(b)

(c)

Group

Sum Number of Physician UPINs per Beneficiary

Mean Number of Physician UPINs per Beneficiary

Median Number of Physician UPINs per Beneficiary

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

433,829

13.3919

12

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

500,679

11.2215

10

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

181,513

9.2689

8

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

417,751

8.0997

7

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

337,732

7.7802

6

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

953,450

6.9683

6

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

884,283

4.9764

4

X—No Condition Category Assigned

4,118,603

3.9818

3

Total in Groups

3,681,210

7.2764

6

Total in File

7,730,303

5.0191

4

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

(a)–(g) Carrier file; physician providers; regardless of condition.

(h) Carrier file; physician providers; condition related claims only.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

(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

 

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

TABLE D-3 Proportion of Beneficiaries with 1–10+ Physicians Billing for Care

 

(a)

(b)

(c)

(d)

(e)

Group

Total Beneficiaries w/ Physician Providers

1 Physician UPIN per Beneficiary

2–5 Physician UPINs per Beneficiary

6–9 Physician UPINs per Beneficiary

10+ Physician UPINs per Beneficiary

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

32,395

0.96%

14.14%

23.36%

61.54%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

44,618

2.01%

20.13%

26.33%

51.53%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

19,583

4.22%

29.95%

27.39%

38.44%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

51,576

2.99%

33.94%

31.84%

31.23%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

43,409

6.87%

35.76%

27.42%

29.95%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

136,826

4.70%

40.07%

31.75%

23.48%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

177,694

11.25%

55.46%

22.35%

10.94%

X—No Condition Category Assigned

1,034,357

19.90%

56.42%

17.73%

5.94%

Total in Groups

505,912

6.52%

40.69%

26.91%

25.88%

Total in File

1,540,183

15.51%

51.26%

20.75%

12.49%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on Health Care Financing Administration specialty code.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

TABLE D-4 Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider

 

(a)

(b)

(c)

(d)

(e)

(f)

Group

Total Beneficiaries w/ Physician Providers

70–100% of Payments to Provider

50–69% of Payments to Provider

35–49% of Payments to Provider

20–34% of Payments to Provider

0–19% of Payments to Provider

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

32,395

7.93%

16.70%

27.14%

37.67%

10.55%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

44,618

11.28%

18.86%

28.39%

33.97%

7.51%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

19,583

17.11%

21.43%

26.98%

28.52%

5.96%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

51,576

15.93%

24.47%

30.28%

25.98%

3.33%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

43,409

21.61%

22.61%

26.14%

25.14%

4.51%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

136,826

20.59%

25.83%

29.18%

21.96%

2.42%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

177,694

31.20%

27.71%

24.75%

14.68%

1.66%

X—No Condition Category Assigned

1,034,357

38.66%

25.71%

20.48%

10.61%

4.54%

Total in Groups

505,912

22.17%

24.72%

27.23%

22.43%

3.44%

Total in File

1,540,183

33.26%

25.41%

22.73%

14.50%

4.10%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on Health Care Financing Administration specialty code.

The beneficiary is counted once in the highest provider category.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

TABLE D-5 Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider for the Condition

 

(a)

(b)

(c)

(d)

(e)

(f)

Group

Total Beneficiaries w/ Physician Providers

70–100% of Payments to Provider

50–69% of Payments to Provider

35–49% of Payments to Provider

20–34% of Payments to Provider

0–19% of Payments to Provider

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

32,225

22.11%

27.09%

28.26%

20.06%

2.48%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

43,652

38.42%

28.40%

21.24%

10.79%

1.15%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

19,173

43.67%

27.13%

18.69%

9.46%

1.05%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

50,844

41.55%

32.17%

19.33%

6.40%

0.54%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

38,728

67.81%

18.59%

8.56%

3.49%

1.55%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

128,289

68.20%

21.93%

6.78%

1.51%

1.57%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

169,507

68.97%

21.18%

6.84%

1.61%

1.40%

Total in Groups

482,071

59.03%

23.67%

11.47%

4.48%

1.35%

Total in File

473,080

59.85%

23.72%

11.14%

4.00%

1.29%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only; condition related.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “”Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

The beneficiary is counted once in the highest provider category.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

TABLE D-6 Proportion of Beneficiaries Associated with a Percent of Physician Provider Claims Allocated to One Provider

 

(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

32,395

6.24%

16.31%

23.24%

37.84%

16.37%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

44,618

8.90%

18.53%

23.51%

35.89%

13.17%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

19,583

16.05%

22.89%

22.64%

29.42%

8.99%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

51,576

11.88%

23.14%

26.31%

32.03%

6.64%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

43,409

19.75%

24.23%

21.37%

27.15%

7.49%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

136,826

14.47%

24.46%

25.30%

30.56%

5.21%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

177,694

28.96%

30.22%

20.48%

18.09%

2.25%

X—No Condition Category Assigned

1,034,357

33.27%

30.74%

17.47%

17.08%

1.44%

Total in Groups

505,912

18.80%

25.24%

23.00%

26.97%

5.99%

Total in File

1,540,183

28.52%

28.95%

19.32%

20.36%

2.85%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

The beneficiary is counted once in the highest provider category.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

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%

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

169,507

68.24%

23.79%

4.23%

3.61%

0.13%

Total in Groups

482,071

52.63%

27.87%

8.97%

9.60%

0.93%

Total in File

473,080

53.44%

28.06%

8.77%

9.02%

0.72%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only; condition related.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

The beneficiary is counted once in the highest provider category.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

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%

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

(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%

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

 

(i)

(j)

(k)

Group

Imaging— Payment ($)

Imaging— Percent

Durable Medical Equipment— Payment ($)

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

18,813,256

10%

32,163

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

23,283,835

11%

14,252

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

7,044,547

9%

16,958

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

26,396,528

15%

30,039

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

13,824,528

10%

11,321

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

65,119,481

17%

52,823

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

38,948,223

11%

116,824

X—No Condition Category Assigned

186,770,390

13%

392,111

Total in Groups

193,430,400

13%

274,380

Total in File

380,200,790

13%

666,491

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

(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

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

TABLE D-9 Average Parts A & B Enrollment by Beneficiary Designation

(a)

Class

(b)

Total Months

(c)

Beneficiaries

(d)

Average Months

Total

24,110,216

2,110,869

11.42

Over 65

20,642,413

1,803,117

11.45

Disabled

3,418,342

303,270

11.27

ESRD

206,976

19,445

10.64

Hospice

281,438

36,306

7.75

Medicare Advantage

3,333,810

287,241

11.61

Deceased

627,655

96,879

6.48

Entered

898,723

131,829

6.82

NOTES:

Enrolled in either Part A or Part B.

Classifications are not mutually exclusive. A beneficiary can be in more than one class.

TABLE D-10 Preventive Services

Service

Total Carrier File Payments

Associated Beneficiaries

GI Tract Work-up After Initial Diagnosis of Iron Deficiency Anemia

$1,908,370.72

8,239

Breast Cancer Screening

$15,871,566.27

245,365

Total

$17,779,936.99

253,604

NOTES:

There were 1151 beneficiaries with both iron deficiency anemia and breast cancer.

Payments include all claims from the carrier file regardless of physician provider or fee-schedule designation.

ACEPRO Analysis had a more limited population and resulted in 208,341 benes for breast cancer screening and 5,977 for iron deficiency anemia.

TABLE D-11 Vaccine Payments

Vaccination Type

Total Carrier File Payments

Total

$11,788,264.27

Influenza

$1,841,885.65

Pneumococcal

$9,946,378.62

NOTES:

Payments include all claims from the carrier file regardless of physician provider or fee-schedule designation.

Pneumococcal vaccine included CPT codes 90658, 90660, and G0008.

Influenza vaccine included CPT codes 90732 and G0009.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

TABLE D-12 Evaluation and Management Claims—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care

Group

Total Beneficiaries w/ Physician Providers

1 Physician UPIN per Beneficiary

2–5 Physician UPINs per Beneficiary

Less than 5 Physician UPINs per Beneficiary

6–9 Physician UPINs per Beneficiary

10+ Physician UPINs per Beneficiary

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

32,755

1.43%

22.60%

24.03%

28.50%

47.47%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

44,850

2.79%

30.02%

32.81%

30.56%

36.64%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

19,784

5.49%

39.67%

45.17%

27.56%

27.28%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

52,230

4.13%

46.59%

50.72%

30.77%

18.51%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

43,610

8.93%

44.87%

53.80%

26.44%

19.76%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

137,709

6.73%

52.87%

59.60%

27.88%

12.52%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

180,054

14.18%

61.81%

75.98%

17.79%

6.22%

X—No Condition Category Assigned

1,016,725

24.06%

59.87%

83.93%

13.22%

2.85%

Total in File

1,529,789

18.84%

56.57%

75.42%

17.06%

7.53%

Total in Groups

510,910

8.54%

50.25%

58.79%

24.76%

16.45%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

TABLE D-13 Evaluation and Management Claims—Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider

Group

Total Beneficiaries w/ Physician Providers

70–100% of Payments to Provider

50–69% of Payments to Provider

35–49% of Payments to Provider

More than 35% of Payments to Providers

20–34% of Payments to Provider

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

32,755

7.41%

15.73%

25.76%

48.90%

37.85%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

44,850

10.45%

18.46%

27.34%

56.24%

34.30%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

19,784

17.56%

21.68%

25.93%

65.16%

28.14%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

52,230

13.23%

21.39%

29.56%

64.19%

30.36%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

43,610

21.69%

22.88%

25.37%

69.94%

24.98%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

137,709

17.20%

23.19%

28.71%

69.10%

26.65%

G—Diabetes; not Chronic Heart Failure &x Coronary Artery Disease

180,054

29.74%

27.65%

24.09%

81.47%

15.88%

X—No Condition Category Assigned

1,016,725

34.44%

24.98%

19.93%

79.35%

12.20%

Total in File

1,529,789

29.70%

24.50%

22.13%

76.33%

16.42%

Total in Groups

510,910

20.39%

23.61%

26.48%

70.48%

24.58%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

The beneficiary is counted once in the highest provider category.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

TABLE D-14 Evaluation and Management Claims for Beneficiaries with Hospitalization—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care

Group

Total Beneficiaries w/ Physician Providers

1 Physician UPIN per Beneficiary

2–5 Physician UPINs per Beneficiary

Less than 5 Physician UPINs per Beneficiary

6–9 Physician UPINs per Beneficiary

10+ Physician UPINs per Beneficiary

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

27,991

0.67%

16.62%

17.29%

28.52%

54.19%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

35,523

1.07%

21.28%

22.35%

32.60%

45.05%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

13,119

1.49%

26.88%

28.37%

32.35%

39.28%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

26,155

1.19%

28.29%

29.48%

37.00%

33.52%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

25,536

1.89%

31.18%

33.07%

34.49%

32.44%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

56,770

1.47%

32.77%

34.23%

38.89%

26.88%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

39,281

2.18%

35.73%

37.91%

36.24%

25.86%

X—No Condition Category Assigned

144,518

2.79%

41.30%

44.09%

35.50%

20.41%

Total in File

368,810

1.97%

33.46%

35.44%

35.23%

29.34%

Total in Groups

224,284

1.45%

28.42%

29.86%

35.05%

35.09%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

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

Group

Total Beneficiaries w/ Physician Providers

70–100% of Payments to Provider

50–69% of Payments to Provider

35–49% of Payments to Provider

More than 35% of Payments to Providers

20–34% of Payments to Provider

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

27,991

5.40%

14.18%

24.97%

44.55%

40.33%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

35,523

6.67%

15.92%

27.32%

49.91%

38.52%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

13,119

9.72%

18.55%

27.01%

55.27%

35.16%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

26,155

6.37%

16.03%

28.65%

51.05%

39.29%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

25,536

10.44%

19.67%

28.01%

58.12%

34.21%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

56,770

7.26%

17.41%

29.75%

54.42%

37.99%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

39,281

10.08%

19.82%

29.83%

59.73%

33.59%

X—No Condition Category Assigned

144,518

11.59%

21.19%

29.72%

62.50%

32.09%

Total in File

368,810

9.31%

18.86%

28.86%

57.03%

35.20%

Total in Groups

224,284

7.83%

17.37%

28.31%

53.51%

37.16%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

The beneficiary is counted once in the highest provider category.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

TABLE D-16 Evaluation and Management Claims for Beneficiaries without Hospitalization—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care

Group

Total Beneficiaries w/ Physician Providers

Total Benes not Hospitalized/ total Benes (from Table 1)

1 Physician UPIN per Beneficiary

2–5 Physician UPINs per Beneficiary

Less than 5 Physician UPINs per Beneficiary

6–9 Physician UPINs per Beneficiary

10+ Physician UPINs per Beneficiary

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

4,751

14.50%

5.87%

57.90%

63.78%

28.44%

7.79%

B—Chronic Heart Failure Coronary Artery Disease; not Diabetes

9,303

20.74%

9.35%

63.49%

72.84%

22.81%

4.35%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

6,661

33.67%

13.38%

64.90%

78.28%

18.14%

3.59%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

26,081

49.93%

7.07%

64.94%

72.01%

24.52%

3.47%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

18,093

41.49%

18.84%

64.15%

82.99%

15.06%

1.95%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

80,628

58.55%

10.47%

67.23%

77.70%

20.23%

2.07%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

140,725

78.16%

17.53%

69.11%

86.64%

12.65%

0.71%

X—No Condition Category Assigned

872,733

85.84%

27.57%

62.91%

90.48%

9.52%

 

Total in File

1,161,313

75.91%

24.20%

63.90%

88.09%

11.28%

0.63%

Total in Groups

286,237

56.02%

14.12%

67.42%

81.54%

16.74%

1.73%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

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

Group

Total Beneficiaries w/ Physician Providers

70–100% of Payments to Provider

50–69% of Payments to Provider

35–49% of Payments to Provider

More than 35% of Payments to Providers

20–34% of Payments to Provider

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

4,751

19.24%

24.92%

30.46%

74.62%

23.05%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

9,303

24.90%

28.20%

27.40%

80.49%

18.03%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

6,661

33.00%

27.86%

23.71%

84.57%

14.07%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

26,081

20.10%

26.74%

30.42%

77.26%

21.26%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

18,093

37.54%

27.38%

21.61%

86.53%

11.82%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

80,628

24.27%

27.33%

28.00%

79.60%

18.51%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

140,725

35.23%

29.84%

22.43%

87.50%

10.82%

X—No Condition Category Assigned

872,733

38.20%

25.59%

18.29%

82.08%

8.82%

Total in File

1,161,313

36.17%

26.27%

19.94%

82.38%

10.35%

Total in Groups

286,237

30.26%

28.51%

25.00%

83.77%

14.54%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

The beneficiary is counted once in the highest provider category.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

TABLE D-18 Evaluation and Management Claims Excluding Place of Service 21—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care

Group

Total Beneficiaries w/ Physician Providers

1 Physician UPIN per Beneficiary

2–5 Physician UPINs per Beneficiary

Less than 5 Physician UPINs per Beneficiary

6–9 Physician UPINs per Beneficiary

10+ Physician UPINs per Beneficiary

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

32,545

3.28%

42.82%

46.09%

37.11%

16.80%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

44,347

5.17%

50.55%

55.72%

32.79%

11.49%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

19,586

8.06%

57.62%

65.68%

26.81%

7.52%

D—Diabetes &Coronary Artery Disease; not Chronic Heart Failure

52,038

5.35%

57.14%

62.49%

29.90%

7.61%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

43,012

12.20%

60.68%

72.88%

22.45%

4.67%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

137,266

7.91%

61.31%

69.22%

25.81%

4.97%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

179,095

15.06%

66.60%

81.66%

16.42%

1.92%

X—No Condition Category Assigned

1,013,335

24.79%

62.48%

87.26%

11.98%

0.76%

Total in File

1,524,716

19.81%

61.65%

81.46%

15.96%

2.59%

Total in Groups

507,067

10.02%

60.53%

70.55%

24.04%

5.41%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

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

Group

Total Beneficiaries w/ Physician Providers

70–100% of Payments to Provider

50–69% of Payments to Provider

35–49% of Payments to Provider

More than 35% of Payments to Providers

20–34% of Payments to Provider

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

32,545

10.99%

20.11%

29.55%

60.66%

33.62%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

44,347

15.12%

22.59%

29.02%

66.73%

29.08%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

19,586

21.96%

25.77%

27.15%

74.88%

22.15%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

52,038

15.63%

24.15%

30.50%

70.28%

26.81%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

43,012

27.08%

26.25%

25.43%

78.76%

18.88%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

137,266

19.42%

25.12%

29.08%

73.62%

23.74%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

179,095

31.21%

28.88%

24.18%

84.27%

13.86%

X—No Condition Category Assigned

1,013,335

35.47%

25.56%

19.80%

80.83%

10.99%

Total in File

1,524,716

31.25%

25.63%

22.24%

79.12%

14.52%

Total in Groups

507,067

23.06%

25.97%

27.18%

76.20%

21.17%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

The beneficiary is counted once in the highest provider category.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

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

Group

Total Beneficiaries w/ Physician Providers

1 Physician UPIN per Beneficiary

2–5 Physician UPINs per Beneficiary

Less than 5 Physician UPINs per Beneficiary

6–9 Physician UPINs per Beneficiary

10+ Physician UPINs per Beneficiary

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

27,755

2.83%

40.02%

42.85%

38.61%

18.54%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

35,157

4.00%

46.63%

50.64%

35.42%

13.94%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

12,942

5.25%

52.95%

58.20%

31.41%

10.39%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

26,000

3.58%

48.44%

52.02%

35.57%

12.42%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

24,932

7.25%

57.42%

64.68%

28.10%

7.22%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

56,449

4.15%

52.38%

56.53%

34.12%

9.35%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

38,834

5.60%

55.50%

61.10%

30.61%

8.29%

X—No Condition Category Assigned

142,327

6.84%

58.52%

65.35%

27.98%

6.66%

Total in File

364,383

5.45%

53.70%

59.15%

31.41%

9.44%

Total in Groups

221,524

4.57%

50.73%

55.30%

33.69%

11.00%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

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

Group

Total Beneficiaries w/ Physician Providers

70–100% of Payments to Provider

50–69% of Payments to Provider

35–49% of Payments to Provider

More than 35% of Payments to Providers

20–34% of Payments to Provider

A—Diabetes, Chronic Heart Failure & Coronary Artery Disease

27,755

9.56%

19.23%

29.35%

58.14%

35.53%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

35,157

12.39%

20.96%

29.33%

62.68%

32.16%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

12,942

16.01%

24.57%

28.78%

69.36%

26.60%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

26,000

10.99%

21.25%

30.43%

62.67%

32.64%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

24,932

19.16%

25.26%

28.26%

72.68%

24.30%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

56,449

12.26%

21.84%

30.69%

64.79%

31.44%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

38,834

15.76%

24.65%

30.46%

70.87%

25.85%

X—No Condition Category Assigned

142,327

17.65%

24.95%

29.15%

71.75%

25.21%

Total in File

364,383

15.06%

23.36%

29.59%

68.01%

28.23%

Total in Groups

221,524

13.43%

22.39%

29.91%

65.73%

30.12%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

The beneficiary is counted once in the highest provider category.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

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

Group

Total Beneficiaries w/ Physician Providers

1 Physician UPIN per Beneficiary

2–5 Physician UPINs per Beneficiary

Less than 5 Physician UPINs per Beneficiary

6–9 Physician UPINs per Beneficiary

10+ Physician UPINs per Beneficiary

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

4,757

5.91%

59.41%

65.31%

28.61%

6.08%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

9,299

9.51%

64.77%

74.28%

22.45%

3.27%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

6,653

13.53%

66.62%

80.15%

17.81%

2.04%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

26,002

7.13%

65.92%

73.06%

24.27%

2.68%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

18,016

19.10%

65.39%

84.49%

14.70%

0.81%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

80,798

10.54%

67.57%

78.11%

20.00%

1.88%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

140,048

17.71%

69.78%

87.49%

12.51%

 

X—No Condition Category Assigned

872,829

27.66%

62.99%

90.65%

9.35%

 

Total in File

1,155,308

24.42%

64.43%

88.85%

11.16%

 

Total in Groups

285,293

14.26%

68.19%

82.44%

16.57%

0.99%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

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

Group

Total Beneficiaries w/ Physician Providers

70–100% of Payments to Provider

50–69% of Payments to Provider

35–49% of Payments to Provider

More than 35% of Payments to Providers

20–34% of Payments to Provider

A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease

4,757

19.45%

25.37%

30.84%

75.66%

22.33%

B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes

9,299

25.24%

28.50%

27.56%

81.30%

17.44%

C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease

6,653

33.50%

28.05%

23.73%

85.29%

13.48%

D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure

26,002

20.28%

27.06%

30.57%

77.91%

20.80%

E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease

18,016

38.15%

27.70%

21.52%

87.37%

11.17%

F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure

80,798

24.43%

27.42%

27.95%

79.79%

18.33%

G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease

140,048

35.54%

30.10%

22.41%

88.05%

10.36%

X—No Condition Category Assigned

872,829

38.31%

25.61%

18.25%

82.17%

8.72%

Total in File

1,155,308

36.49%

26.44%

19.93%

82.86%

9.91%

Total in Groups

285,293

30.55%

28.76%

25.03%

84.34%

14.08%

NOTES:

Claim lines with invalid provider numbers have been removed from the physician file for all tables.

Carrier file data only.

Outliers above 99 percent have been removed.

Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups.

Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

The beneficiary is counted once in the highest provider category.

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×

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).

Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 180
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 181
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 182
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 183
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 184
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 185
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 186
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 187
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 188
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 189
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 190
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 191
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 192
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 193
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 194
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 195
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 196
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 197
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 198
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 199
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 200
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 201
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 202
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 203
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 204
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 205
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 206
Suggested Citation:"Appendix D: MEDPAC Data Runs." Institute of Medicine. 2007. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press. doi: 10.17226/11723.
×
Page 207
Next: Appendix E: Pay for Performance in Various Care Settings »
Rewarding Provider Performance: Aligning Incentives in Medicare Get This Book
×
Buy Hardback | $60.00
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

The third installment in the Pathways to Quality Health Care series, Rewarding Provider Performance: Aligning Incentives in Medicare, continues to address the timely topic of the quality of health care in America. Each volume in the series effectively evaluates specific policy approaches within the context of improving the current operational framework of the health care system. The theme of this particular book is the staged introduction of pay for performance into Medicare. Pay for performance is a strategy that financially rewards health care providers for delivering high-quality care. Building on the findings and recommendations described in the two companion editions, Performance Measurement and Medicare's Quality Improvement Organization Program, this book offers options for implementing payment incentives to provide better value for America’s health care investments.

This book features conclusions and recommendations that will be useful to all stakeholders concerned with improving the quality and performance of the nation’s health care system in both the public and private sectors.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!