Medicare Hospital and Physician Data Release: A Different Perspective

on Tuesday, 16 June 2015. All News Items | Case Management | Quality | Outpatient Services | Billing

CMS Releases Annual Medicare Hospital, Physician and Other Supplier Utilization and Payment Data

As David Letterman’s late night show recently came to a close I fondly reminisce about his “Top 10” lists. A quick search on Google will give you the Best of the David Letterman Top 10 Lists for example the Top Ten Least Popular Exhibits at the Baseball Hall of fame, the Top Ten Least Popular Attractions at Disney World and the Top Ten Least Popular Broadway Shows. It seems that the Centers for Medicare and Medicaid Services (CMS) has embraced this Top 10 concept as they highlighted the Top 10 Medicare DRGs by volume for FY 2013 in a related Fact Sheet regarding their recent annual release of Medicare Hospital and Physician Data.

Last week our article focused on detailing information about the data. This week we take a closer look at the data from a different perspective by highlighting the Top 10 Things to Know about the HFMA Region 5: Dixie States (AL, FL, GA, SC, and TN) specific data.

1. Tennessee has had the lowest increase in their Medicare Fee-for-Service Part A Enrollment (see Table 1).

Table 1

Beneficiary State of ResidenceMedicare Beneficiaries Enrolled in FFS Part AChange in Part A Enrollment from 2011 to 2013
201120122013
United States 35,489,737 36,161,158 36,559,356 (+)1,069,619
Alabama 680,329 696,024 704,204 (+)23,875
Florida 2,360,330 2,371,543 2,384,355 (+)24,025
Georgia 981,607 1,007,921 1,018,757 (+)37,150
South Carolina 662,728 680,094 689,134 (+)26,406
Tennessee 808,401 815,995 813,926 (+)5,525

 

2. Tennessee has in fact seen a decrease in their Medicare Fee-for-Service Part B Enrollment (see Table 2).

Both the Part A and Part B enrollment decline may be due to the fact that Medicare Advantage Enrollment in Tennessee has been consistently higher than the national average in 2013, 2014, and 2015 (See Table 3).

Table 2

Beneficiary State of ResidenceMedicare Beneficiaries Enrolled in FFS Part BChange in Part B Enrollment from 2011 to 2013
201120122013
United States 32,812,557 33,259,978 33,540,864 (+)728,307
Alabama 640,851 654,556 662,002 (+)21,151
Florida 2,199,161 2,199,292 2,207,095 (+)7,934
Georgia 922,766 943,261 952,033 (+)29,267
South Carolina 631,904 646,453 653,551 (+)21,647
Tennessee 755,150 758,570 754,047 (-)1,103

 

Table 3

Medicare Advantage Enrollees as Percent of Total Medicare Population20112012201320142015
United States 26% 27% 28% 30% 31%
Alabama 21% 22% 22% 24% 25%
Florida 32% 34% 36% 38% 40%
Georgia 22% 24% 25% 28% 31%
South Carolina 16% 18% 20% 22% 23%
Tennessee 25% 27% 29% 32% 34%
Source: Henry J. Kaiser Family Foundation State Health Facts at:          
http://kff.org/medicare/state-indicator/enrollees-as-a-of-total-medicare-population/  

 

3. From 2011 to 2013 only six (6) of the Top 10 DRGs by Volume saw an increase in volume in the Dixie States.

  1. DRG 470: Major Joint Replacement or Reattachment of Lower Extremity without MCC
  2. DRG 871: Septicemia or Severe Sepsis without Mechanical Vent 96+ Hours with MCC
  3. DRG 291: Heart Failure & Shock with MCC
  4. DRG 683: Renal Failure with CC
  5. DRG 190: Chronic Obstructive Pulmonary Disease with MCC
  6. DRG 193: Simple Pneumonia & Pleurisy with MCC

4. Likewise, from 2011 to 2013 four (4) of the Top 10 DRGs by Volume saw a decrease in volume in the Dixie States.

  1. DRG 392: Esophagitis, Gastroenteritis & Miscellaneous Digestive Disorders without MCC
  2. DRG 292: Heart Failure & Shock with CC
  3. DRG 194: Simple Pneumonia & Pleurisy with CC
  4. DRG 690: Kidney & Urinary Tract Infections without MCC

5. Overall volume for the Top 10 DRGs from 2011 to 2013 decreased for all five (5) states combined from 372,865 discharges in 2011 to 371,623 discharges in 2013.

6. By volume, Florida had the most discharges in the Top 10 DRGs in all three years (FY 2011, 2012, and 2013) with 475,828 discharges.

7. By volume, South Carolina had the least discharges in the Top 10 DRGs in all three years (FY 2011, 2013, and 2013) with 117,026 discharges.

8. The DRG with the largest increase in volume overall was DRG 871: Septicemia or Severe Sepsis without Mechanical Vent 96+ Hours with MCC. The number of discharges in 2011 was 46,571 and increased to 57,010 in 2013.

What you need to know about sepsis:

Sepsis is on your hospital PEPPER report. It is important to review and determine if you are an outlier above or below your State, MAC Jurisdiction and the Nation. If you are an outlier above now is the time for a record review to ensure that clinical indicators validate a diagnosis of sepsis.

9. The DRG with the largest decrease in volume overall was DRG 392: Esophagitis, Gastroenteritis & Miscellaneous Digestive Disorders without MCC.

What you need to know about DRG 392:

This can be viewed as a positive as prior to the implementation of the 2-Midnight Rule, this DRG was consistently the target of Recovery Auditors and a high percentage of hospitals were reporting medical necessity denials in the American Hospital Association’s RACTrac Quarterly Reports.

10. From 2011 to 2013 “Average Covered Charges” were higher for all of the Top 10 DRGs by Volume. However, the “Average Medicare Payments” were lower for eight (8) of the DRGs for the Dixie States (see Table 4).

  1. DRG 470: Major Joint Replacement or Reattachment of Lower Extremity without MCC
  2. DRG 871: Septicemia or Severe Sepsis without Mechanical Vent 96+ Hours with MCC
  3. DRG 292: Heart Failure & Shock with CC
  4. DRG 194: Simple Pneumonia & Pleurisy with CC
  5. DRG 690: Kidney & Urinary Tract Infections without MCC
  6. DRG 683: Renal Failure with CC
  7. DRG 190: Chronic Obstructive Pulmonary Disease with MCC
  8. DRG 193: Simple Pneumonia & Pleurisy with MCC

Table 4

Region 5: HFMA Dixie
(AL, FL, GA, SC, TN)
DRG DefinitionCMS Fiscal YearTotal DischargesAverage Covered ChargesAverage Total PaymentsAverage Medicare Payments
470 - MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC 2011 67,464 $52,931.06 $12,928.53 $10,709.11
2012 67,871 $55,379.44 $12,957.83 $10,548.67
2013 69,671 $57,951.69 $13,032.85 $10,537.98
871 - SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W MCC 2011 46,571 $47,175.18 $11,958.94 $10,830.01
2012 49,852 $49,510.07 $12,044.46 $10,876.85
2013 57,010 $50,811.66 $12,010.51 $10,685.00
392 - ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC 2011 43,312 $19,870.40 $4,520.54 $3,387.35
2012 36,711 $22,637.79 $4,648.52 $3,431.15
2013 34,514 $23,463.31 $4,753.34 $3,433.75
292 - HEART FAILURE & SHOCK W CC 2011 38,099 $22,725.83 $6,286.88 $5,405.54
2012 34,554 $23,660.81 $6,270.44 $5,375.68
2013 33,668 $24,944.15 $6,220.62 $5,174.35
291 - HEART FAILURE & SHOCK W MCC 2011 32,606 $35,692.06 $9,257.59 $8,337.85
2012 31,534 $36,927.23 $9,255.16 $8,349.61
2013 33,338 $39,207.79 $9,476.45 $8,416.93
194 - SIMPLE PNEUMONIA & PLEURISY W CC 2011 31,520 $25,772.18 $6,227.95 $5,137.70
2012 29,089 $26,808.37 $6,177.83 $5,061.00
2013 30,362 $27,894.17 $6,263.55 $5,012.62
690 - KIDNEY & URINARY TRACT INFECTIONS W/O MCC 2011 37,016 $18,787.79 $4,778.46 $3,854.16
2012 36,330 $20,153.11 $4,828.47 $3,838.63
2013 32,433 $21,374.20 $4,838.05 $3,772.34
683 - RENAL FAILURE W CC 2011 26,835 $24,071.23 $6,310.68 $5,317.76
2012 27,429 $25,090.28 $6,317.51 $5,317.50
2013 27,397 $25,798.36 $6,236.84 $5,082.41
190 - CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC 2011 27,588 $28,700.93 $7,267.73 $6,229.05
2012 25,933 $29,999.28 $7,148.24 $6,057.87
2013 28,274 $31,789.96 $7,307.74 $6,144.66
193 - SIMPLE PNEUMONIA & PLEURISY W MCC 2011 21,854 $38,016.08 $9,060.90 $8,007.91
2012 21,774 $38,766.20 $9,197.77 $8,040.56
2013 24,956 $40,373.42 $9,237.59 $7,967.06
Note: Includes discharges from Hospitals located within the HFMA Region 5  

 

For additional information you can access the Press Release and Fact Sheets posted to the CMS website from the following links:

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-four years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

green-iconWe are an environmentally conscious company, dedicated to living “green” both at work and as individuals.

Location

home-icon
1900 Twentieth Avenue South
Suite 220
Birmingham, AL 35209

Connect

phone
205-941-1105
phone
800-592-9639
email
This email address is being protected from spambots. You need JavaScript enabled to view it.

 

 mhms