About the Project
Episode groupers create condition-specific episodes of care (EOC) from administrative claims data. Services delivered by providers over a defined period of time can be analyzed and grouped by specific clinical conditions to generate an overall picture of the services required to treat and manage that condition for a given patient. Grouping claims at the EOC level affords the opportunity to make meaningful comparisons about clinical conditions between providers on the basis of cost and resource use. The method by which claims are grouped and attributed can vary significantly between methodologies, resulting in the need for consensus-based metrics for evaluation.
Episode groupers present a number of challenges, particularly in the presence of multiple and concurrent episodes as well as comorbidities. Decision logic is built into the grouper to distinguish claims from different episodes for the same patient from each other. Additionally, episode grouper software relies on clean, accurate data to generate a true picture of the services delivered to the patient for a given condition. Non-standardized data fields create the need for additional analysis and abstraction to provide reliable data for the episode grouper. Furthermore, the presence of multiple payers for a patient, as well as the exclusion of pharmacy claims can create additional data problems.
The National Quality Forum (NQF) has undertaken several projects relating to both the development of episode of care evaluation frameworks as well as the consideration of episode grouper methodology during the evaluation of cost and resource use measures. The Patient-Centered Episodes of Care Framework was completed in 2010 and resulted in a framework intended to provide guidance to help policymakers, healthcare leaders, and other key stakeholder groups move toward a high-performing healthcare system that is patient-centered, focused on quality, mindful of costs, and vigilant against waste. NQF also conducted the evaluation of measures containing grouper methodology during the second phase of the Efficiency endorsement project resulting in the endorsement of several condition-specific measures of resource use.
The goals of this project are to:
- Define the characteristics of an episode grouper versus other measurement systems, including classification or risk adjustment systems
- Review and modify as needed existing NQF criteria and guidance and/or provide additional recommendations for the evaluation of an episode grouper
- Examine the necessary submission elements for the evaluation of an episode grouper
- Review the best practices for the construction of an episode grouper
NQF Process
This project will be guided by an expert panel. The panel will use relevant elements of NQF's Consensus Development Process to meet and review comments. However, as this project will not include the review and assessment of consensus standards, it will not include a member voting period.
Related Work
Funding
This project is funded under a contract provided by the Department of Health and Human Services.
For information about the availability of auxiliary aids and services for NQF’s federally funded projects, please visit: http://www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html.
Contact Information
For further information, contact Ashlie Wilbon, RN, MPH at 202-783-1300 or via email at groupercriteria@qualityforum.org.