This document details the methodology for the Medicare Spending Per Beneficiary (MSPB) Clinician measure and should be reviewed along with the Measure Codes List file, which contains the medical codes used in constructing the measure.
The MSPB Clinician measure assesses the cost to Medicare of services provided to a patient during an MSPB Clinician episode (hereafter referred to as the “episode”), which comprises the period immediately prior to, during, and following the patient’s hospital stay. An episode includes Medicare Part A and Part B claims with a start date between 3 days prior to a hospital admission (also known as the “index admission” for the episode) through 30 days after hospital discharge, excluding a defined list of services that are unlikely to be influenced by the clinician’s care decisions and are, thus, considered unrelated to the index admission. In all supplemental documentation, the term “cost” generally means the standardized1 Medicare allowed amount. 2
MSPB Clinician is an important means of measuring Medicare spending, as health expenditures continue to increase in the United States. Total health care spending is estimated to have increased by 4.6% in 2017, reaching $3.5 trillion, and spending for Medicare, which is still predominantly paid on a fee-for-service (FFS) basis, grew by 3.6%, reaching $672.1 billion.3 In 2016, Medicare FFS paid $183 billion for approximately 10 million Medicare inpatient admissions and 200 million outpatient services, which reflects a 2.3% increase in hospital spending per FFS patient between 2015 and 2016 (MedPAC, 2018). Given that the inpatient hospital setting is such an important contributor to overall Medicare spending, gauging the efficacy of this spending requires measuring the cost performance of clinicians providing care at hospitals. The MSPB Clinician measure provides valuable context for such progress in efficiency by comparing the movement in costs associated with hospital admissions.
As background to this revised measure, a version of the MSPB Clinician measure has been part of the Merit-based Incentive Payment System (MIPS) Cost performance category since the 2017 MIPS performance period. Prior to this use in MIPS, the Centers for Medicare & Medicaid Services (CMS) used the MSPB measure in the Value Modifier (VM) Program and reported it in annual Quality and Resource Use Reports (QRURs) until the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the VM Program. The MSPB Clinician measure has undergone re-evaluation to address stakeholder feedback received from prior public comment periods and was finalized for 2020 MIPS performance period.
Patient Exclusion Criteria
Patients’ episodes are excluded from the measure population if the patients meet any of the following conditions:
- They were not enrolled in both Medicare Parts A and B for the entirety of the lookback period plus episode window.
- They were enrolled in a private Medicare health plan (e.g., a Medicare Advantage or a Medicare private FFS plan) for any part of the lookback period plus episode window.
- They resided outside the United States or its territories during any month of the performance period.
The numerator for the MSPB Clinician measure is the sum of the ratio of payment-standardized observed to expected episode costs for all episodes attributed to the clinician group, as identified by a unique Medicare Taxpayer Identification Number (TIN), or to the clinician, as identified by a unique TIN and National Provider Identifier pair (TIN-NPI). The sum is then multiplied by the national average payment-standardized observed episode cost to generate a dollar figure.
The denominator for the MSPB Clinician measure is the total number of episodes attributed to a clinician or clinician group.
The MSPB Clinician 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)
The MSPB Clinician cost measure can be triggered at acute care facility hospitals.
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 Part A and Part B Price (Payment) Standardization - Basics" and “CMS Part A and B Price (Payment) Standardization - Detailed Methods” documents posted on the CMS Price (Payment) Standardization Overview webpage. (https://www.resdac.org/articles/cms-price-payment-standardizationoverview)
2 Cost is defined by allowed amounts on Medicare claims data, which include both Medicare trust fund payments and any applicable patient deductible and coinsurance amounts.
3 “National Health Expenditure Projections, 2017-2026.” US Centers for Medicare & Medicaid Services, 2018