Introduction
This document details the methodology for the Emergency Medicine measure and should be reviewed along with the Emergency Medicine Measure Codes List file, which contains the medical codes used in constructing the measure.
Measure Description
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 Emergency Medicine episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who have an emergency department (ED) visit 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 measure includes costs of Part A and B services during each episode from the start of the ED visit that opens, or “triggers,” the episode through 14 days after the trigger, excluding a defined list of services for each ED visit type that are unrelated to the ED care.
Measure Rationale
Emergency department (ED) care is costly, with Medicare outpatient hospital program spending on ED visits increasing from $2.3 billion to $4.1 billion from 2011 to 2017.3 ED clinicians play a key role in the decision to admit a patient, and appropriate admissions from the ED should be emergent and necessary, as determined by a patient’s diagnosis.4 However, admission rates vary widely across the country and across hospitals,5,6 as well as across clinicians within hospitals,7 likely due to factors other than patient characteristics.8 The high costs associated with ED care and variation in admission rates indicate opportunities for improvement to potentially improve outcomes and lower costs of care. The Emergency Medicine episode-based cost measure was selected for development because of its high impact in terms of patient population and Medicare spending, and the opportunity for incentivizing cost-effective, highquality clinical care in this area. Following initial feedback gathered during the Wave 4 public comment period,9 the subsequent measure-specific clinician expert workgroup provided extensive, detailed input on this measure.
Measure Numerator
The cost measure numerator is the sum of the ratio of observed to expected10 paymentstandardized cost to Medicare for all Emergency Medicine episodes attributed to a clinician. This sum is then multiplied by the national average observed episode cost to generate a dollar figure.
Measure Denominator
The cost measure denominator is the total number of episodes from the Emergency Medicine episode group attributed to a clinician.
Data Sources
The Emergency Medicine cost measure uses the following data sources:
- Medicare Part A and B claims data from the Common Working File (CWF)
- Enrollment Data Base (EDB)
- Long Term Care Minimum Data Set (LTC MDS)11
Care Settings
Methodologically, the Emergency Medicine cost measure can be triggered based on claims data from the emergency department (ED).
Cohort
The cohort for this cost measure consists of patients who are Medicare beneficiaries enrolled in Medicare fee-for-service and who receive care during an ED visit that triggers an Emergency Medicine episode.
The cohort for this cost measure is also further refined by the definition of the episode group and exclusions (refer to Section 4).
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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://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.
3 Medicare Payment Advisory Commission. Options for slowing the growth of Medicare fee-for-service spending for emergency department services. (June 2019). https://www.medpac.gov/document/http-wwwmedpac-gov-docs-default-source-reports-jun19_ch11_medpac_reporttocongress_sec-pdf/
4 A. K. Sabbatini, B. K. Nallamothu, and K. E. Kocher, "Reducing Variation in Hospital Admissions from the Emergency Department for Low-Mortality Conditions May Produce Savings," Health Aff (Millwood) 33, no. 9 (Sep 2014). https://doi.org/10.1377/hlthaff.2013.1318
5 Sukayna Z. Alfaraj and Jesse M. Pines, "What We Can Learn from Medicare Data on Early Deaths after Emergency Department Discharge," Journal of Thoracic Disease 9, no. 7 (2017). https://doi.org/10.21037/jtd.2017.06.44
6 J. M. Pines, R. L. Mutter, and M. S. Zocchi, "Variation in Emergency Department Admission Rates across the United States," Med Care Res Rev 70, no. 2 (Apr 2013). https://doi.org/10.1177/1077558712470565
7 Jameel Abualenain et al., "Emergency Department Physician-Level and Hospital-Level Variation in Admission Rates," Annals of emergency medicine 61, no. 6 (2013/06// 2013). https://doi.org/10.1016/j.annemergmed.2013.01.016.
8 Smulowitz, P. B., A. J. O'Malley, L. Zaborski, J. M. McWilliams, and B. E. Landon. "Variation in Emergency Department Admission Rates among Medicare Patients: Does the Physician Matter?". Health Aff (Millwood) 40, no. 2 (Feb 2021): 251-57. https://doi.org/10.1377/hlthaff.2020.00670
9 “Wave 4 Public Comment Summary,” QPP Cost Measure Information, Prior cost measure development and input (https://www.cms.gov/medicare/quality-payment-program/cost-measures/prior).
10 Expected costs refer to costs predicted by the risk adjustment model. For more information on expected costs and risk adjustment, please refer to Section 4.5.
11 For information on how LTC MDS data are used in risk adjustment, please refer to Section 4.5.