Introduction
This document details the methodology for the Respiratory Infection Hospitalization measure and should be reviewed along with the Respiratory Infection Hospitalization 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 Respiratory Infection Hospitalization episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who receive inpatient treatment for a respiratory infection 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 30 days after the trigger.
Measure Rationale
Pneumonia is a leading infectious cause of hospitalization and death among adults in the United States. 3 Respiratory infections are also a significant cause of morbidity and mortality in the older adult populations, who may be more susceptible to respiratory conditions due to factors such as greater comorbidities, potential for compromised immune systems, or higher likelihood of malnutrition that are often associated with age.4,5 For individuals over 65 years old, mortality rates increases by approximately 6-7% with the presence of respiratory infections.6 As such, respiratory conditions represent a significant share of US health care spending, totaling $170.8 billion in 2016.7 Given the prevalence of respiratory infections in the Medicare population and increase in associated health care expenditures, the Respiratory Infection Hospitalization measure represents an opportunity for improvement on overall cost performance.
The Simple Pneumonia with Hospitalization episode-based cost measure, which preceded the Respiratory Infection Hospitalization measure, was originally selected for development based on input from an expert clinician committee—the Pulmonary Disease Management Clinical Subcommittee—because of its impact in terms of patient population and clinician coverage, and the opportunity for incentivizing cost-effective, high-quality clinical care in this clinical area. This Clinical Subcommittee, which was originally convened during Wave 1 of episode-based cost measure development and met several times throughout 2017 to provide input on the full measure specifications, was reconvened as a workgroup in October 2022 to discuss updates to the measure as a part of the comprehensive measure reevaluation process, resulting in the Respiratory Infection Hospitalization measure.
Measure Numerator
The cost measure numerator is the sum of the ratio of observed to expected8 payment-standardized cost to Medicare for all Respiratory Infection Hospitalization 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 Respiratory Infection Hospitalization episode group attributed to a clinician.
Data Sources
The Respiratory Infection Hospitalization 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)9
Care Settings
Methodologically, the Respiratory Infection Hospitalization cost measure can be triggered based on claims data from: acute inpatient (IP) hospitals.
Cohort
The cohort for this cost measure consists of patients who are Medicare beneficiaries enrolled in Medicare fee-for-service and who receive inpatient treatment for a respiratory infection that triggers a Respiratory Infection Hospitalization episode.
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 (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 Regunath, Hariharan, and Yuji Oba. “Community-Acquired Pneumonia.” National Library of Information, August 8, 2022. https://www.ncbi.nlm.nih.gov/books/NBK430749
4 Rojas, Mauricio, Ana L Mora, Maria Kapetanaki, Nathaniel Weathington, Mark Gladwin, and Oliver Eickelberg. “Aging and Lung Disease. Clinical Impact and Cellular and Molecular Pathways.” Annals of the American Thoracic Society. U.S. National Library of Medicine, December 2015. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6137674
5 Akhtar, Ali, Mohamed Azmi Ahmad Hassali, Hadzliana Zainal, Irfhan Ali, Muhammad Shahid Iqbal, and Amer Hayat Khan. “Respiratory-Tract Infections among Geriatrics: Prevalence and Factors Associated with the Treatment Outcomes.” Therapeutic advances in respiratory disease. U.S. National Library of Medicine, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8108383
6 Ibid.
7 Duan, Kevin I, Maxwell Birger, David H Au, Laura J Spece, Laura C Feemster, and Joseph L Dieleman. “U.S. Health Care Spending on Respiratory Diseases, 1996-2016.” ATS Journals. American Journal of respiratory and Critical Care Medicine, August 23, 2022. https://www.atsjournals.org/doi/abs/10.1164/rccm.202202-0294OC?journalCode=ajrccm
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 4.5.
9For information on how LTC MDS data are used in risk adjustment, please refer to Section 4.5.