July 2, 2019

Episode groupers: a crucial tool for population health management

A practical guide to episode groupers for cost-of-illness analysis in health services research

Summary of analytic components in selected episode groupers.

ProductEpisode exampleSample conceptual focusaNumber of episodesClinical settingPublic episode definitionLinked risk-adjustment approach
3M Patient-focused Episode SoftwareNot reported.• Event-based episodes per patient
• Cohort-based episodes among patients with a shared condition or characteristic
>500AllNo3M Clinical Risk Groups
Cave GrouperUrinary tract infection• Physician relative efficiency and effectiveness scores
• High-cost patient prediction
>500AllNoCCGroup MediScreen
CMS-BPCIUrinary tract infectionInpatient and post-acute care~50Inpatient, skilled nursing facility, inpatient rehabilitation facility, long-term care hospital or home health agencyYesNo
McKinsey & CompanyPerinatalPrincipal Accountable Provider>100AllYesYesb
Optum Symmetry Episode Treatment GroupsPregnancy, with delivery• Patient total cost of care by condition categories
• Provider profiling
>500AllYesOptum Symmetry Episode Risk Groups
OptumInsight Symmetry Procedure Episode GroupsRadical hysterectomy• Medical and surgical procedure cost
• Provider profiling
~200AllNoOptum Symmetry Episode Risk Groups
Prometheus AnalyticsPregnancyPotentially avoidable complications~100AllYesPrometheus Analytics risk adjustment
Medical Episode GrouperCardiac arrhythmias• Population profiling
• Provider profiling
>500AllNoDisease Staging and Diagnostic Cost Groups
Information as of January 2019 in public documentation reviewed for this article, which comprised peer-reviewed articles and Internet searches for vendor product names; sources as cited in the References list. Readers are encouraged to check those and related sources for more details and updated information on the groupers briefly summarized here.
CMS-BPCI Centers for Medicaid and Medicare Services’ Bundled Payments for Care Improvement.
aAs highlighted in public documentation primarily from vendors; this is not an exhaustive list of conceptual orientations among profiled groupers.
bNot detailed in public documentation reviewed for this article in cited sources.