This document details the methodology for the Asthma/Chronic Obstructive Pulmonary Disease (COPD) measure and should be reviewed along with the Asthma/Chronic Obstructive Pulmonary Disease (COPD) 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, the term “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A, B, and D3 are used to construct this episode-based cost measure.
The Asthma/COPD episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care to manage and treat asthma or COPD. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during an Asthma/COPD episode.
Research has shown that both asthma and COPD are highly prevalent, costly conditions within the United States population, and their overall disease burden and financial impact continue to rise. 4,5 COPD is the third leading cause of death in the United States.6 In 2014, 15.7 million Americans were diagnosed with COPD, yet this number could be an underestimation since many people with low lung function are not aware they have COPD.7 The Centers for Disease Control and Prevention estimated that COPD-related costs grew by nearly $17 billion in the past decade in the United States, equating to an overall increase of 53%.8,9 Specifically, Medicare paid 51% of these COPD-related costs.10 One study found that the mean total health care costs were $20,500 higher among Medicare patients with COPD compared to those without COPD.11
Among the many factors that contribute to rising health care costs associated with COPD, increasing hospitalization and readmission rates are among the highest cost drivers.12 COPD is the fourth leading cause of 30-day readmissions, where nearly one-fifth of patients hospitalized for an acute exacerbation of COPD were readmitted within 30 days of discharge. 13,14,15
More than 25 million Americans live with asthma,16 and it has been estimated that 5% of all Medicare patients have an asthma diagnosis.17 The total cost incurred for treatment of asthma was $81.9 billion in 2013.18 Recent estimates attribute more than 10 million lost work days among employed adults and nearly 2 million emergency department (ED) visits over a single year to asthma.19 Much like COPD, the burden of asthma falls heavily on adults aged 65 years and older, who have the highest mortality rate for the condition compared to any other age group.
Despite the differences in etiology, symptoms, and responses to therapy between asthma and COPD, these diseases overlap in disease presentation and pathophysiologic characteristics.20,21
There is also a substantial 15 to 20% overlap in the reported prevalence of comorbid cases of asthma and COPD.22 This overlapping relationship places an important role on clinicians to follow appropriate guidelines and utilize proper management strategies to classify and treat patients accurately.23 Given the high impact in terms of patient population and Medicare spending, the Asthma/COPD measure represents an opportunity for improvement on overall cost performance. The Asthma/COPD episode-based cost measure was selected for development based on input from an expert clinician committee—the Chronic Condition and Disease Management Clinical Subcommittee—because of its impact in terms of patient population and clinician coverage, and for incentivizing cost-effective, high-quality clinical care in this clinical 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 measure numerator is the weighted average ratio of the winsorized24 scaled standardized observed cost to the scaled expected25 cost for all Asthma/COPD episodes attributed to a clinician, where each ratio is weighted by each episode’s number of days assigned to a clinician. This sum is then multiplied by the national average winsorized scaled observed episode cost to generate a dollar figure.
The measure denominator is the total number of days from Asthma/COPD episodes assigned to the clinician across all patients.
The Asthma/COPD measure uses the following data sources:
- Medicare Part A, B, and D claims data from the Common Working File (CWF)
- Enrollment Database (EDB)
- Long Term Care Minimum Data Set (LTC MDS)26
The Asthma/COPD measure focuses on the care provided by clinicians practicing in non-inpatient hospital settings for patients with asthma or COPD. The most frequent settings in which an Asthma/COPD episode is triggered include: office, skilled nursing facility (SNF), and outpatient hospital.
The cohort for this cost measure consists of patients who are Medicare beneficiaries enrolled in Medicare fee-for-service who receive medical care to manage and treat asthma or COPD.
The cohort for this cost measure is also further refined by the definition of the episode group and measure-specific exclusions (refer to Section 4).
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 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-standardization-overview).
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
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-Payment-Pro...).
4 Centers for Disease Control and Prevention. "Basics About COPD." https://www.cdc.gov/copd/basics-about.html.
5 Asthma and Allergy Foundation of America. "Cost of Asthma on Society." https://www.aafa.org/cost-of-asthma-on-society/.
6 American Lung Association. "How Serious Is COPD." https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/copd/l....
7 Centers for Disease Control and Prevention. "Basics About COPD." https://www.cdc.gov/copd/basics-about.html.
8 Ford, Earl S., Louise B. Murphy, Olga Khavjou, Wayne H. Giles, James B. Holt, and Janet B. Croft. "Total and State-Specific Medical and Absenteeism Costs of COPD among Adults Aged 18 Years in the United States for 2010 and Projections Through 2020." CHEST 147, no. 1 (2015): 31-45.
9 Centers for Disease Control and Prevention. "COPD Costs." https://www.cdc.gov/copd/infographics/copd-costs.html.
11 Menzin, Joseph, Luke Boulanger, Jeno Marton, Lisa Guadagno, Homa Dastani, Riad Dirani, Amy Phillips, and Hemal Shah. "The Economic Burden of Chronic Obstructive Pulmonary Disease (COPD) in a U.S. Medicare Population." Respiratory Medicine 102, no. 9 (2008): 1248-56.
12 Parikh, Raj, Trushil G. Shah, and Rajive Tandon. "COPD Exacerbation Care Bundle Improves Standard of Care, Length of Stay, and Readmission Rates." International Journal of Chronic Obstructive Pulmonary Disease 11 (2016): 577-83.
14 Jencks, Stephen F., Mark V. Williams, and Eric A. Coleman. "Rehospitalizations Among Patients in the Medicare Fee-for-Service Program." The New England Journal of Medicine 360, no. 14 (2009): 1418-28.
16 Asthma and Allergy Foundation of America. "Asthma Facts and Figures." https://www.aafa.org/asthma-facts/.
17 Centers for Medicare & Medicaid Services. "Health Disparities in the Medicare Population: Asthma." https://www.cms.gov/files/document/2016-05-cms-omh-data-snapshot-asthma-....
18 Nurmagambetov, Tursynbek, Robin Kuwahara, and Paul Garbe. "The Economic Burden of Asthma in the United States, 2008–2013." Annals of the American Thoracic Society 15, no. 3 (2018): 348-56.
19 American Lung Association. "Asthma in Adults Fact Sheet." https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma....
20 Guarascio, Anthony J., Shauntá M. Ray, Christopher K. Finch, and Timothy H. Self. "The Clinical and Economic Burden of Chronic Obstructive Pulmonary Disease in the USA." ClinicoEconomics and Outcomes Research 5 (2013): 235-45.
21 Cukic, Vesna, Vladimir Lovre, Dejan Dragisic, and Aida Ustamujic. "Asthma and Chronic Obstructive Pulmonary Disease (COPD) - Differences and Similarities." Materia Socio-Medica 24, no. 2 (2012): 100-05.
22 Global Initiative for Chronic Obstructive Lung Disease. "Diagnosis of Diseases of Chronic Airflow Limitation: Asthma, COPD, and Asthma-Copd Overlap Syndrome (ACOS)." https://goldcopd.org/wp-content/uploads/2016/04/GOLD_ACOS_2015.pdf.
23 Guarascio, Anthony J., Shauntá M. Ray, Christopher K. Finch, and Timothy H. Self. "The Clinical and Economic Burden of Chronic Obstructive Pulmonary Disease in the USA." ClinicoEconomics and Outcomes Research 5 (2013): 235-45.
24 For information on how costs are winsorized, please refer to Section 4.7.
25 Expected costs refer to costs predicted by the risk adjustment model. For more information on expected costs and risk adjustment, please refer to Section 4.7.
26 For information on how LTC MDS data are used in risk adjustment, please refer to Section 4.7.