Introduction
This document details the methodology for the Hemodialysis Access Creation measure and should be reviewed along with the Hemodialysis Access Creation Measure Codes List file, which contains the medical codes used in constructing the measure.
Measure Description
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
The Hemodialysis Access Creation episode-based cost measure evaluates a clinician’s riskadjusted cost to Medicare for beneficiaries who undergo a procedure for the creation of graft or fistula access for long-term hemodialysis during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 60 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
Measure Rationale
In 2015, there were 124,114 newly reported cases of end-stage renal disease (ESRD), bringing the total number of people with ESRD to 703,243. Patients aged 65 and older accounted for over 207,000 of those cases of ESRD and accounted for approximately half of all individuals who received hemodialysis access for that year, a 22 percent increase from 2010. However, for new cases of ESRD, less than 20 percent begin hemodialysis using either a fistula or a graft, which confer decreased morbidity and mortality rates and lower cost.3 The United States Renal Data System (USRDS) 2017 Annual Data Report found that Medicare spent $33.9 billion on beneficiaries with ESRD, and when combined with the cost of Chronic Kidney Disease (CKD), a total of over $98 billion. For hemodialysis care, Medicare spent a total of $88,750 per patient per year, excluding unknown modalities, and $1,677 for vascular access procedures (procedures to place or create vascular accesses and procedures to maintain them).4 The Hemodialysis Access Creation episode-based cost measure was recommended for development by an expert clinician committee—the Peripheral Vascular Disease Management Clinical Subcommittee— because of its high impact in terms of patient population and Medicare spending, and the opportunity for incentivizing cost-effective, high-quality clinical care in this area. Based on the initial recommendations from the Clinical Subcommittee, the subsequent measure-specific workgroup provided extensive, detailed input on this measure.
Measure Numerator
The cost measure numerator is the sum of the ratio of observed to expected5 paymentstandardized cost to Medicare for all Hemodialysis Access Creation episodes attributed to a clinician. This sum is then multiplied by the national average observed episode cost to generate a dollar figure.
Measure Denominator
The cost measure denominator is the total number of episodes from the Hemodialysis Access Creation episode group attributed to a clinician.
Data Sources
The Hemodialysis Access Creation cost measure uses the following data sources:
- Medicare Parts A and B claims data from the Common Working File (CWF)
- Enrollment Data Base (EDB)
- Long Term Care Minimum Data Set (LTC MDS)6
Care Settings
Methodologically, the Hemodialysis Access Creation cost measure can be triggered based on claims data from the following settings: ambulatory/office-based care centers, outpatient (OP) hospitals, and ambulatory surgical centers (ASC).
Cohort
The cohort for this cost measure consists of patients who are Medicare beneficiaries enrolled in Medicare fee-for-service and who undergo a procedure for the creation of graft or fistula access for long-term hemodialysis that triggers a Hemodialysis Access Creation episode.
The cohort for this cost measure is also further refined by the definition of the episode group and measure-specific exclusions (see Appendix A).
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1 - Claim payments are standardized to account for differences in Medicare payments for the same service(s) across Medicare providers. Payment standardized costs remove the effect of differences in Medicare payment among health care providers that are the result of differences in regional health care provider expenses measured by hospital wage indexes and geographic price cost indexes (GPCIs) or other payment adjustments such as those for teaching hospitals. For more information, please refer to the “CMS Price (Payment) Standardization - Basics" and “CMS Price (Payment) Standardization - Detailed Methods” documents posted on the Payment Standardization QualityNet webpage. (https://www.qualitynet.org/inpatient/measures/payment-standardization)
2 - Cost is defined by allowed amounts on Medicare claims data, which include both Medicare trust fund payments and any applicable beneficiary deductible and coinsurance amounts. Claims data from Medicare Parts A and B are used to construct the episode-based cost measures.
3 - Malas, Mahmoud B., Joseph K. Canner, Caitlin W. Hicks, Isibor J. Arhuidese, Devin S. Zarkowsky, Umair Qazi, Eric B. Schneider, James H. Black, Dorry L. Segev, and Julie A. Freischlag. "Trends in Incident Hemodialysis Access and Mortality." JAMA Surgery 150, no. 5 (2015): 441-448.
4 - United States Renal Data System, 2017 Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2017.
5 - Expected costs refer to costs predicted by the risk adjustment model. For more information on expected costs and risk adjustment, please refer to Section A.5.
6 - For information on how LTC MDS data are used in risk adjustment, please refer to Section A.5.