Claims groupings can improve research


In California, Medicaid analysts have the capability to group claims into episodes of care to assess quality and project financial risk.

Claims analysts for Medi-Cal, California’s Medicaid program are assessing quality of care and project financial risk  by grouping and studying data about patients with similar conditions or diagnoses.

Medi-Cal professionals working for the California Department of Health Care Services (DHCS) are utilizing the agency’s management information system/decision support system (MIS/DSS) data warehouse and Optum Symmetry™ software to group claims (and managed-care encounters) into episodes of care, to assign beneficiaries to risk groups and to compare patterns of medical practice to the latest national guidelines for quality care. Symmetry is one of the leading medical informatics grouper systems in the United States. It is licensed by more than 300 health care organizations nationwide, serving millions of individuals.

The clinical grouper information in the California MIS/DSS is provided by three Symmetry modules:

  • Episode Treatment Groups™ (ETG) assigns claims to clinical condition categories — for example, “septicemia” or “cardiac congenital disorder” — that are further defined by the presence of complications and comorbidities. ETG and related information are derived from three years of Medi-Cal claims and corresponding beneficiary eligibility history. Each episode of care is linked to the originating claims and encounters and has clinical attributes that can be used for filtering and reporting.
  • Episode Risk Groups™ (ERG) uses ETG output to calculate relative risk for each Medi-Cal beneficiary and produces risk scores that can be used for actuarial analysis. 
  • Evidence-Based Medicine™ (EBM Connect) is a rules-based engine that assesses whether patient care meets clinical treatment guidelines. EBM Connect includes nearly 600 clinical quality-of-care measures, including most of the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) measures. HEDIS is a tool used by most of America's commercial and government health plans to measure performance on important dimensions of care and service.

The ETG software groups related services from claims tables into clinically homogenous units that describe complete episodes of care, thus providing the basis of valid comparisons. Episodes are created by collecting inpatient, outpatient, pharmacy and ancillary services into mutually exclusive and exhaustive categories.

ETG recognizes comorbidities, complications and treatments that significantly change a patient’s clinical profile, health care utilization and likely future costs. Unlike other groupers, the Symmetry engine uses pharmaceutical prescription history, as well as procedures and diagnoses, to determine and rank a patient’s primary and secondary conditions, both acute and chronic. Symmetry relies on standard national procedure and diagnosis codes for processing, and Optum converts most DHCS local codes into national standard codes so that Symmetry can understand them.

ETG can be used to identify patients with a specific disease or class of disease and subdivide such groups according to the presence of complications and comorbidities. ETG can be used to:

  • Measure and compare the utilization and financial performance of health care providers (provider profiling) 
  • Measure health care demand 
  • Establish disease management strategies, including pharmaceutical claims 
  • Evaluate whether physicians are adhering to treatment guidelines and protocols 
  • Quantify disease burden and cost of treatment for any population breakout

For aggregation and reporting, each ETG base class code is mapped to one major practice category (MPC), which represents a body system or physician specialty (such as pulmonology, psychiatry or endocrinology). This enables reporting of episodes and services by MPC as well as by ETG code.

Because Medi-Cal coverage is month-to-month, gaps in certified coverage are common. ETG data includes a “record type” code that indicates which episodes are complete and which are not complete due to extended gaps in certified coverage or other reasons.