2024 MIPS Cost: Heart Failure Measure


This document details the methodology for the Heart Failure measure and should be reviewed along with the Heart Failure Measure Codes List file, which contains the medical codes used in constructing the measure.

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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, 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 Heart Failure episode-based cost measure evaluates a clinician’s or clinician group’s riskadjusted and specialty-adjusted cost to Medicare for patients receiving medical care to manage and treat heart failure. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Heart Failure episode.


Measure Rationale

Heart failure encapsulates many different conditions, but has two primary types: HFrEF (heart failure with reduced ejection fraction, or systolic heart failure) and HFpEF (heart failure with preserved ejection fraction, or diastolic heart failure).4 The incidence of heart failure increases with age, rising from 20 per 1,000 individuals aged 65 to 69 to more than 80 per 1,000 individuals over 80 years of age.5 With an estimated 1 in 5 Americans 40 years and older expected to develop heart failure and 1 in 5 Americans expected to be 65 years or older by 2050, the number of Americans with heart failure is predicted to significantly increase in the future.6,7 This carries particular weight given that heart failure was listed as the cause of death on 13.4% of all death certificates in the United States in 2018.8 In addition to its prevalence, heart failure is also costly for the health care system. According to the CDC, heart failure costs the United States $30.7 billion annually, including health care services, medications used to treat heart failure, and lost productivity.9 A large contributor to heart failure-related healthcare costs may be inpatient admissions, with one study estimating that roughly 1 in 6 beneficiaries returned to the hospital for admission for heart failure-related reasons within 90 days of their initial discharge.10 Despite the high costs, opportunities for improvement exist to improve patient care and reduce associated costs for patients with heart failure. Several studies have indicated that involving patients with heart failure in disease management programs can prevent readmissions, increase quality of life, and reduce mortality, morbidity, and overall resource use.11,12,13,14 In addition, despite established guideline-directed medical therapies (GDMTs) and evidence of their success in improving morbidity and mortality for patients with heart failure,15,16,17,18 broader adherence to GDMTs may be suboptimal, with some studies indicating that relatively few patients HFrEF are on the appropriate target doses of medical therapy19 and that GDMT promotion and dosing varies across provider specialties.20

Given the prevalence of heart failure in the Medicare population, and the high costs associated with the management of the disease and its complications, the Heart Failure cost measure represents an opportunity for improvement on overall cost performance. The Heart Failure episode-based cost measure was selected for development because of its high impact in terms of patient population, clinician coverage, and Medicare spending, and the opportunity build a complex, yet feasible, chronic condition measure that would address a condition not captured by other cost measures. Following initial feedback gathered during the Wave 4 public comment period,21 the subsequent measure-specific clinician expert workgroup provided extensive, detailed input on this measure.


Measure Numerator

The measure numerator is the weighted average ratio of the winsorized22 scaled standardized observed cost to the scaled expected23 cost for all Heart Failure 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.


Measure Denominator

The measure denominator is the total number of days from Heart Failure episodes assigned to the clinician across all patients.


Data Sources

The Heart Failure 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)24


Care Settings

The Heart Failure measure focuses on the care provided by clinicians practicing in non-inpatient hospital settings for patients with heart failure. The most frequent settings in which a Heart Failure episode is triggered include: office, outpatient hospital, and skilled nursing facility (SNF).



The cohort for this cost measure consists of patients who are Medicare beneficiaries enrolled in Medicare fee-for-service that receive care for heart failure.

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-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 Incorporation of Rebates in Part D Standardized Amounts on the CMS.gov QPP Cost Measures Information Page’s About Cost Measures page (https://www.cms.gov/medicare/quality-payment-program/cost-measures/about).

4 AHA, "Types of Heart Failure," https://www.heart.org/en/health-topics/heart-failure/what-is-heartfailure/types-of-heart-failure

5 Yancy et al. “2013 ACCF/AHA Heart Failure Guidelines.” (2013). https://www.ahajournals.org/doi/pdf/10.1161/CIR.0b013e31829e8776.

6 Ibid.

7 CMS, "Heart Failure Disparities in Medicare Fee-For-Service Beneficiaries."

8 Centers for Disease Control and Prevention (CDC) “Heart Failure.” September 2020. https://www.cdc.gov/heartdisease/heart_failure.htm.

9 Ibid.

10 Kilgore et al., "Economic burden of hospitalizations of Medicare beneficiaries with heart failure," Risk Management and Healthcare Policy 10 (2017): 63-70, doi: 10.2147/RMHP.S130341.

11 Moser, D.K. and D. L. Mann, "Improving Outcomes in Heart Failure: It's Not Unusual Beyond Usual Care," Circulation 105, no. 24 (June 2002): 2810-2812, https://doi.org/10.1161/01.cir.0000021745.45349.bb

12 Koser et al., "An Outpatient Heart Failure Clinic Reduces 30-Day Readmission and Mortality Rates for Discharged Patients: Process and Preliminary Outcomes," Journal of Nursing Research 26, no. 6 (December 2018): 393-398, https://doi.org/10.1097/jnr.0000000000000260

13 Rich et al., "A Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with Congestive Heart Failure,” New England Journal of Medicine 333, no. 18 (November 1995):1190-1195, https://doi.org/10.1056/NEJM199511023331806

14 Stewart, Simon and John Horowitz, "Home-Based Intervention in Congestive Heart Failure," Circulation 105 (May 2002): 2861-2866, doi: doi:10.1161/01.CIR.0000019067.99013.67

15 Roth et al., "Use of Guideline-Directed Medications for Heart Failure before Cardioverter-Defibrillator Implantation," Journal of the American College of Cardiology 67, no. 9 (March 2016): 1062-1069, https://doi.org/10.1016/j.jacc.2015.12.046

16 Fonarow, Greg and Boback Ziaeian, "Gaps in Adherence to Guideline-Directed medical Therapy before Defibrillator Implantation," Journal of the American College of Cardiology 67, no. 9 (2016). https://doi.org/10.1016/j.jacc.2015.12.045

17 Luzier et al., "Containment of heart failure hospitalizations and cost by angiotensin-converting enzyme inhibitor dosage optimization," The American Journal of Cardiology 86, no. 5 (September 2000): 519-523, doi: https://doi.org/10.1016/S0002-9149(00)01005-5

18 Chen et al., “Angiotensin-converting enzyme inhibitor dosages in elderly patients with heart failure," American Heart Journal 141, no. 3 (March 2001):410-417, doi: https://doi.org/10.1067/mhj.2001.113227
19 Komajda et al., "Physicians' Adherence to Guideline-Recommended Medications in Heart Failure with Reduced Ejection Fraction: Data from the Qualify Global Survey," European Journal of Heart Failure 18, no. 5 (May 2016): 514-522, https://doi.org/10.1002/ejhf.510

20 Edep et al., "Differences Between Primary Care Physicians and Cardiologists in Management of Congestive Heart Failure: Relation to Practice Guidelines," Journal of the American College of Cardiology 30, no 2 (August 1997): 518-526, doi: https://doi.org/10.1016/S0735-1097(97)00176-9.

21 “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)

22 For information on how costs are winsorized, please refer to Section 4.7.

23 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.

24 For information on how LTC MDS data are used in risk adjustment, please refer to Section 4.7.

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