Introduction
This document details the methodology for the Kidney Transplant Management measure and should be reviewed along with the Kidney Transplant Management 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, 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 Kidney Transplant Management 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 related to kidney transplant, beginning 90 days post-transplant. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Kidney Transplant Management episode.
Measure Rationale
There are several opportunities for improvement and high-value care for kidney transplant patients. An analysis using the US Renal Data System of over 40,000 transplant recipients from 2005-2014 found that post-transplant readmissions make up 20% of all Medicare payments for transplantation, but up to half of these readmissions can be preventable.4 Readmissions within 30 days that have the highest costs are those associated with surgical complications, transplant rejection, and infection.5
Following clinical guidelines to test, screen, and monitor patients according to their level of risk, and following medication best practices, can also impact cost and quality of care. There is demonstrated variation in frequency of patient visits to transplant centers, by transplant center and region,6 suggesting opportunities for improvement in graft monitoring and reducing complications. Appropriate routine graft monitoring is important as it may ensure early detection of pathologies and reduce risk of graft failure. Research supports screening regularly for diabetes, hypertension, dyslipidemias, tobacco use, and obesity, to initiate early management of these conditions’ interactions with kidney transplants.7
Clinicians can help lower drug costs as well as improve quality of management by following evidence-based guidelines. For instance, clinicians can optimize the dosage of long-term maintenance immunosuppressive medications by ensuring patients are on the lowest planned doses of maintenance medications by 2-4 months, absent transplant rejection.8 Clinicians can also follow additional published strategies to reduce drug costs, such as limiting the use of biologic agents for induction to patients at high risk of acute rejection and using lower-cost biosimilars when available. Care coordination can also ensure that responsible clinicians are aware of prescription changes and that patients are monitored following changes in medication regime.
Patient education may play a role in hospital readmissions and overall quality of care.9 Patient education regarding medication adherence, anticipated side effects and expected symptoms, diet, healthy lifestyle, as well as tobacco and proteinuria screening at office visits can also impact outcomes,10 as non-adherence has been shown to be associated with a high risk of acute rejection an allograft loss. Kidney transplant management care teams should have a system in place to address patient non-adherence, such as leveraging social workers, financial counselors, pharmacists, and others to engage with the patient and their family and monitor medication or other treatment adherence.
The Kidney Transplant Management episode-based cost measure was selected for development based on input from the Chronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD) Clinician Expert Workgroup as well as the Wave 5 Public Comment Period, where experts and other interested members of the public recommended a parallel cost measure evaluating kidney transplant alongside the development of cost measures for stage 4 and 5 CKD and for ESRD. Clinical experts and other commenters noted that including the kidney transplant recipient population in cost measurement would align with the kidney care community's emphasis on post-transplant care and would help create beneficial incentives for providers.
Measure Numerator
The measure numerator is the weighted average ratio of the winsorized11 scaled standardized observed cost to the scaled expected12 cost for all Kidney Transplant Management 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 Kidney Transplant Management episodes assigned to the clinician across all patients.
Data Sources
The Kidney Transplant Management measure uses the following data sources:
- Medicare Part A, B, and D claims data from the Common Working File (CWF)
- Enrollment Data Base (EDB)
- Long Term Care Minimum Data Set (LTC MDS)13
- Organ Procurement and Transplantation Network (OPTN)
Care Settings
The Kidney Transplant Management measure focuses on the care provided by clinicians practicing in non-inpatient hospital settings for patients with care related to kidney transplant. The most frequent settings in which a Kidney Transplant Management episode is triggered include: office and outpatient hospital.
Cohort
The cohort for this cost measure consists of patients who are Medicare beneficiaries enrolled in Medicare fee-for-service who receive medical care related to kidney transplant, beginning 90 days post-transplant.
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).
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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 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 CMS.gov QPP Cost Measures Information Page’s About Cost Measures page (https://www.cms.gov/medicare/quality-payment-program/cost-measures/about).
4 Hogan J et al. Assessing predictors of early and late hospital readmission after kidney transplantation. Transplantation direct. 2019 Aug;5(8).
5 Famure O, Kim ED, Au M, Zyla RE, Huang JW, Chen PX, Li Y, Kim SJ. What Are the Burden, Causes, and Costs of Early Hospital Readmissions After Kidney Transplantation? Prog Transplant. 2021 Jun;31(2):160-167. doi: 10.1177/15269248211003563. Epub 2021 Mar 24. PMID: 33759628; PMCID: PMC8182333.
6 Israni AK, Snyder JJ, Skeans MA, Tuomari AV, Maclean JR, Kasiske BL. Who is caring for kidney transplant patients? Variation by region, transplant center, and patient characteristics. Am J Nephrol. 2009;30(5):430-439.
7 Bia M, Adey DB, Bloom RD, Chan L, Kulkarni S, Tomlanovich S. KDOQI US commentary on the 2009 KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Kidney Dis. 2010 Aug;56(2):189-218. doi: 10.1053/j.ajkd.2010.04.010.
8 Ibid.
9Harhay, M et al. Early rehospitalization after kidney transplantation: assessing preventability and prognosis. American Journal of Transplantation. 2013 Dec;13(12):3164-72.
10Ibid.
11For information on how costs are winsorized, please refer to Section 4.7.
12Expected 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.
13For information on how LTC MDS data are used in risk adjustment, please refer to Section 4.7.