This document details the methodology for the Femoral or Inguinal Hernia Repair measure and should be reviewed along with the Femoral or Inguinal Hernia Repair 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 Femoral or Inguinal Hernia Repair episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who undergo surgical procedure to repair a femoral or inguinal hernia 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 procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
In the US, more than 1 million hernias are treated and or repaired annually, the majority of which are inguinal hernias.3 On average, these hernia repair procedures cost approximately $2,000 to $2,500, representing nearly $2.5 billion in annual health care costs.4 Opportunities for improvement for elective femoral or inguinal hernia repair are primarily found within the variation in hernia repair techniques, where utilization of optimal techniques and protocols may produce improved outcomes and potentially lower the cost of care during the episode. The Femoral or Inguinal Hernia Repair episode-based cost measure was recommended for development by an expert clinician committee—the Gastrointestinal Disease Management - Medical and Surgical Clinical Subcommittee—because of its impact in terms of patient population and clinician coverage, 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 expert workgroup provided extensive, detailed input on this measure.
The cost measure numerator is the sum of the ratio of observed to expected5 payment standardized cost to Medicare for all Femoral or Inguinal Hernia Repair 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 Femoral or Inguinal Hernia Repair episode group attributed to a clinician.
The Femoral or Inguinal Hernia Repair 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
Methodologically, the Femoral or Inguinal Hernia Repair cost measure can be triggered based on claims data from acute inpatient (IP) hospitals, hospital outpatient departments (HOPD), ambulatory/office-based care centers, and ambulatory surgical centers (ASC).
The cohort for this cost measure consists of patients who are Medicare beneficiaries enrolled in Medicare fee-for-service and who undergo surgical procedure to repair a femoral or inguinal hernia that triggers a Femoral or Inguinal Hernia Repair 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 Matthews, R. Douglas, and Leigh Neumayer. "Inguinal Hernia in the 21st Century: An Evidence-Based Review." Current Problems In Surgery 45, no. 4 (2008): 257-59.
4 Rutkow, Ira M. "Demographic and Socioeconomic Aspects of Hernia Repair in the United States in 2003." The Surgical Clinics Of North America 83, no. 5 (2003): 1045.
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.