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Development of an Administrative Claims-Based Prospective Risk Tier Method for Percutaneous Coronary Intervention Episodes of Care

Fowler, Erica N, Fowler
http://orcid.org/0000-0002-1917-7610
http://rave.ohiolink.edu/etdc/view?acc_num=osu1542467861407973

Abstract Details

2018, Doctor of Philosophy, Ohio State University, Public Health.
Bundled payments are gaining traction in the commercial health care market as a viable value-based reimbursement payment model. Bundled payments benefit payers, providers, and patients by lowering the cost of care, establishing and enforcing standardized care pathways, and improving health outcomes. This dissertation examines percutaneous coronary intervention (PCI) procedures in the context of bundled payments, examines differences in outcomes by sex, and proposes a framework that can be used to prospectively identify risk factors for patients who will undergo PCI. We used the proprietary analytics tool, Episode Workbench™ from Aver Inc, to apply episode logic from Provider Payment Reform for Outcomes, Margins, Evidence, Transparency, Hassle-reduction, Excellence, Understandability and Sustainability (PROMETHEUS) Analytics, an open-source bundled payment methodology which represents the most widely used method to define episodes of care, to a large sample of commercially-insured patients from the 2014-2015 Truven Health MarketScan Commercial Claims and Encounters Research Database. In the first aim, we identified episodes eligible to be included in pricing analyses and examined differences by sex. We found that almost one-third of all episodes were ineligible for inclusion in pricing analyses due to young age, non-continuous enrollment in insurance plan submitting data to the Truven database, missing facility claims, or extremely high or low total episode cost indicating a catastrophic case or missing data. Males comprised almost three-quarters of eligible episodes and a higher percentage of females experienced patient safety- or system-related post-surgical complications and readmissions. In the second aim, we used generalized linear regression to predict episode cost from the payer perspective using demographics, comorbidities, and health care utilization data to predict total episode cost. The total cost of care in the 12 months prior to the index surgery and geographic region were the strongest predictors of episode cost. As cost of care in the 12 months prior to the PCI increased, episode cost increased and episode costs were higher in the West region. The observed and predicted episode costs were weakly associated. In the third aim, we used generalized linear regression models to predict episode cost from the provider perspective using demographics and comorbidities in the 12 months prior to the index surgery to predict total episode cost. Geographic region was the strongest predictor of episode cost, with higher cost in the West than other regions. For inpatient episodes, acute myocardial infarction or diabetes mellitus with complications in the 12 months prior to the index surgery was also associated with higher episode cost. The observed and predicted episode costs were very weakly associated. Although the current study did not yield a useful model for predicting episode cost for PCI, it is the first to examine a framework to prospectively identify risk factors for increased cost in the context of bundled payments. Integration of data from payers and providers should be used to risk-stratify patients prior to the procedure. Such risk stratification will allow payers and providers to appropriately price episodes of care to minimize potential for downside risk, increase provider participation, and bundle payments to benefit a broader patient population.
Amy Ferketich, PhD (Advisor)
Julie Bower, PhD, MPH, FAHA (Committee Co-Chair)
Randi Foraker , PhD, MA, FAHA (Committee Member)
Michael Pennell, PhD, MS (Committee Member)
Reanne Frank, PhD, MS (Committee Member)
118 p.
Public Health
value-based reimbursement; bundled payments; percutaneous coronary intervention

Recommended Citations

Citations

  • Fowler, Fowler, E. N. (2018). Development of an Administrative Claims-Based Prospective Risk Tier Method for Percutaneous Coronary Intervention Episodes of Care [Doctoral dissertation, Ohio State University]. OhioLINK Electronic Theses and Dissertations Center. http://rave.ohiolink.edu/etdc/view?acc_num=osu1542467861407973

    APA Style (7th edition)

  • Fowler, Fowler, Erica. Development of an Administrative Claims-Based Prospective Risk Tier Method for Percutaneous Coronary Intervention Episodes of Care . 2018. Ohio State University, Doctoral dissertation. OhioLINK Electronic Theses and Dissertations Center, http://rave.ohiolink.edu/etdc/view?acc_num=osu1542467861407973.

    MLA Style (8th edition)

  • Fowler, Fowler, Erica. "Development of an Administrative Claims-Based Prospective Risk Tier Method for Percutaneous Coronary Intervention Episodes of Care ." Doctoral dissertation, Ohio State University, 2018. http://rave.ohiolink.edu/etdc/view?acc_num=osu1542467861407973

    Chicago Manual of Style (17th edition)

osu1542467861407973
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© 2018, all rights reserved.
This open access ETD is published by The Ohio State University and OhioLINK.