This document details the methodology for the Intracranial Hemorrhage or Cerebral Infarction measure and should be reviewed along with the Intracranial Hemorrhage or Cerebral Infarction Measure Codes List file, which contains the medical codes used in constructing the measure.
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 Intracranial Hemorrhage or Cerebral Infarction episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who receive inpatient treatment for cerebral infarction or intracranial hemorrhage during the performance period. The measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
Each year approximately 780,000 people in the United States suffer a new or recurring stroke, and strokes are the leading cause of permanent disability in adults and the third leading cause of death in the US. A 2010 study estimated that ischemic strokes alone were responsible for close to $65.5 billion in healthcare spending in the US because of the need for long-term care after a stroke.3 The Intracranial Hemorrhage or Cerebral Infarction episode-based cost measure was recommended for development by an expert clinician committee—the Neuropsychiatric Disease Management Clinical Subcommittee—because of its impact in terms of patient population and clinician coverage, and the opportunity for incentivizing cost-effective, highquality clinical care in this area. Subsequently, members of the Clinical Subcommittee provided extensive, detailed input on this measure.
The cost measure numerator is the sum of the ratio of observed to expected4 paymentstandardized cost to Medicare for all Intracranial Hemorrhage or Cerebral Infarction episodes attributed to a clinician. This sum is then multiplied by the national average observed episode cost to generate a dollar figure.
The cost measure denominator is the total number of episodes from the Intracranial Hemorrhage or Cerebral Infarction episode group attributed to a clinician.
The Intracranial Hemorrhage or Cerebral Infarction 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)5
Methodologically, the Intracranial Hemorrhage or Cerebral Infarction cost measure can be triggered based on claims data from acute inpatient (IP) hospitals.
The cohort for this cost measure consists of patients who are Medicare beneficiaries enrolled in Medicare fee-for-service and who receive inpatient treatment for cerebral infarction or intracranial hemorrhage that triggers an Intracranial Hemorrhage or Cerebral Infarction 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).
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 CMS Price (Payment) Standardization Overview page. (https://www.resdac.org/articles/cms-price-payment-standardization-overview)
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 - Guilhaume, Chantal, Delphine Saragoussi, John Cochran, Clément François, and Mondher Toumi. "Modeling Stroke Management: A Qualitative Review of Cost-Effectiveness Analyses." The European Journal of Health Economics : HEPAC 11, no. 4 (August 2010): 419-26.
4 - 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.
5 - For information on how LTC MDS data are used in risk adjustment, please refer to Section A.5.