Development of multipayer claims-based emergency department episodes of care.

Abstract

Objectives: To describe the design of multipayer claims-based episodes of care initialized by visits to the emergency department (ED) and to demonstrate the utility of this framework for health care quality improvement work.

Study design: A retrospective analysis of paid medical insurance claims organized into 30-day episodes of care initialized by ED visits for Michigan adult residents with private insurance, Medicare, and Medicaid.

Methods: Thirty-day claims-based episodes of care initialized by ED visits at Michigan hospitals were constructed for 15 medical conditions. Mean episode payments were price standardized and risk adjusted. Analyses described episode payments and postacute care utilization primarily across 6 conditions: abdominal pain, cellulitis, chronic obstructive pulmonary disease, congestive heart failure, nonspecific chest pain, and urinary tract infection.

Results: A total of 2,657,818 ED-based episodes of care for 15 conditions were identified for commercially and government-insured adult patients receiving ED care at 105 Michigan hospitals. Total payments across a 30-day episode of care and utilization of postacute care services varied substantially by condition and across the state, with mean risk-adjusted, price-standardized 30-day total payments for a given episode ranging from $3262 for abdominal pain to $17,941 for congestive heart failure.

Conclusions: Episodes of care created from multipayer claims data can be used to provide insight into opportunities for collaboration and improvement of patients' care continuum following an ED visit.