This document details the methodology for the Sepsis measure and should be reviewed along with the Sepsis 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, B, and D3 are used to construct the episode-based cost measures.
The Sepsis episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who receive inpatient medical treatment for sepsis 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 45 days after the trigger.
Sepsis represents a significant share of hospitalizations and Medicare cost. According to a 2013 national inpatient sample, Medicare inpatient stays with sepsis were the overall most costly type of hospitalization, representing more than 8% of all Medicare costs.4 Hospitalizations with sepsis represent significant mortality,5 longer inpatient stays,6 and significant downstream costs (e.g., a higher likelihood of being discharged to a short-term care facility or long-term care institution relative to other types of hospitalizations), particularly when sepsis progresses to septic shock.7 The Sepsis episode-based cost measure was recommended for development by an expert clinician committee—the Hospital Medicine 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 clinician expert workgroup provided extensive, detailed input on this measure.
The cost measure numerator is the sum of the ratio of observed to expected8 payment standardized cost to Medicare for all Sepsis 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 Sepsis episode group attributed to a clinician.
The Sepsis 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)9
Methodologically, the Sepsis 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 medical treatment for sepsis that triggers a Sepsis episode.
The cohort for this cost measure is also further refined by the definition of the episode group and measure-specific exclusions (refer to 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 Part A and Part B Price (Payment) Standardization - Basics" and “CMS Part A and Part B Price (Payment) Standardization - Detailed Methods” documents posted on the CMS Price (Payment) Standardization Overview page. (https://www.resdac.org/articles/cms-price-payment-standardizationoverview). Claim payments from Part D are payment standardized to allow resource use comparisons for providers who prescribe the same drug, even if the drug products are covered under varying Part D plans, produced by different manufacturers, or dispensed by separate pharmacies. For more information, please refer to the “CMS Part D Price (Payment) Standardization” document posted on the CMS Price (Payment) Standardization Overview page. (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 beneficiary deductible and coinsurance amounts.
3 Part D branded drug costs are also adjusted to account for post-point of sale drug rebates; more information can be found in the Methodology for Rebates in Part D Standardized Amounts on the MACRA Feedback Page (https://www.cms.gov/Medicare/Quality-Payment-Program/Quality-PaymentProgram/Give-Feedback).
4 AHRQ, "Hcup National Inpatient Sample (Nis): Healthcare Cost and Utilization Project (Hcup), 2013."
5 "Data & Reports," 2016, accessed June 19, 2019, 2019, https://www.cdc.gov/sepsis/datareports/index.html.
6 C. J. Paoli et al., "Epidemiology and Costs of Sepsis in the United States-an Analysis Based on Timing of Diagnosis and Severity Level," Crit Care Med 46, no. 12 (Dec 2018). https://doi.org/10.1097/CCM.0000000000003342; M. J. Hall et al., "Inpatient Care for Septicemia or Sepsis: A Challenge for Patients and Hospitals," NCHS Data Brief, no. 62 (Jun 2011).
7 Hall, M. J., S. N. Williams, C. J. DeFrances, and A. Golosinskiy. "Inpatient Care for Septicemia or Sepsis: A Challenge for Patients and Hospitals." [In eng]. NCHS Data Brief, no. 62 (Jun 2011): 1-8.
8 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.
9 For information on how LTC MDS data are used in risk adjustment, please refer to Section A.5.