Comparing Commercial Systems for Characterizing Episodes of Care

Payers are increasingly using episodes of care to measure and reward efficiency in health care. Much attention has been paid to the effects of different rules for assigning episodes to providers, but little to how individual costs are assigned to episodes. In this paper, we studied the extent to which the two most widely-used commercially available episode groupers differ in the episodes they construct. In particular, we compare how much of, and how, the two groupers allocate claims/spending to episodes of care and, for grouped claims, compare the 25 clinical episodes accounting for the greatest share of total spending. Using multi-payer data from the MarketScan Commercial Database, we applied the two most widely used commercial episode groupers: Episode Treatment Groups (ETGs) by Symmetry and Medical Episode Groups (MEGs) by Thomson-Reuters (Medstat).