Abstract
Background/Aims Policymakers are exploring bundled payments to providers, but little is known about their application in ambulatory care. As an example, this study examines the cost of acute bronchitis episodes.
Methods Data were from electronic health records and claims of a large ambulatory group practice with mixed payment sources. Optum’s Symmetry Grouper was used to create episode treatment groups (ETGs) for all services. There were 78,828 episodes of acute bronchitis, cared for by 427 primary care physicians/urgent care centers (PCPs) (1,568 PCP-years) in 2007–2011. Costs included standardized fees for physicians, laboratory/imaging ordered, and specialist services. The grouper extends an episode indefinitely with continuing related services, so we separately considered episodes closed in: (a) 1 day, (b) within 30 days, and (c) those extending beyond 30 days. In a nested model, we focused on lead physician ‘effects,’ controlling for patient characteristics.
Results Of the total episodes, 78% closed in 1 day, 19% closed in 2 to 30 days, and 3% took >30 days. One-day episode costs were most stable (mean cost = $77, coefficient of variation (CV) = 0.36), followed by 30-day episodes (mean cost = $181, CV = 0.56), and longer than 30-day episodes (mean cost = $268, CV = 0.78). Among 1-day episodes, 21% of the PCP-years (with 166 unique PCPs) had costs significantly below the average. Only 22% of the episodes of these PCPs extended beyond 1 day vs. 32% for all other PCPs (P <0.01), and the costs of their longer episodes averaged $176 vs. $205 (P <0.01). Among the 91 PCPs with 2 or more years of significantly lower 1-day costs, 85% (77 PCPs) did not have elevated rates of longer episodes or significantly above average costs for longer episodes.
Conclusions Focusing on 1-day acute bronchitis episodes (78% of the total) markedly reduces the variance across episodes, but substantial variation in episode costs across PCPs remains. With some PCPs repeatedly achieving low 1-day costs without evidence of subsequent problems, episode-based payment may lead to improved resource use.
