Introduction
This document details the methodology for the Rheumatoid Arthritis measure and should be reviewed along with the Rheumatoid Arthritis 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 Rheumatoid Arthritis 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 rheumatoid arthritis. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Rheumatoid Arthritis episode.
Measure Rationale
Rheumatoid arthritis is an autoimmune and inflammatory disease that causes joint pain, disability, and reduced mobility and functional status. Rheumatoid arthritis incidence generally increases with patient age, and the onset is most concentrated among those in their sixties.4 There are several notable improvements in care for patients with rheumatoid arthritis that can positively affect patient outcomes and reduce costs. These clinician actions can include earlier diagnosis, more cost-effective imaging and medication usage, and improved patient relationships. Early diagnosis of rheumatoid arthritis is associated with significantly lower total care costs.5 Research indicates that primary care physicians often fail to order diagnostic tests for rheumatoid arthritis before referring patients with polyarthritis who eventually received an rheumatoid arthritis diagnosis; many such patients also experience greater than 1 year delays from symptom onset to diagnosis.6 Using more cost-effective medications and those with less severe side effects is also important. For example, with some exceptions, synthetic diseasemodifying anti-rheumatic drugs (DMARDs) are an efficacious and higher value first prescription choice instead of costlier biologics, 7,8 and while patients are often prescribed corticosteroids for six months or more,9 guidelines indicate that corticosteroid use should be limited. Further, chronic glucocorticoid use among rheumatoid arthritis patients is associated with a higher health care costs due to increased occurrence of adverse events (e.g., developing diabetes or osteoporosis, cardiovascular events such as thrombotic stroke, myocardial infarction, or death).10,11,12 Though biologic intervention can in some cases favorably affect disease course and yield cost-savings, inadequate clinician-patient communication can hinder both patient awareness about treatment options and physician understanding of patient receptiveness to different modalities.13
Given the impact of rheumatoid arthritis on the older adult population and opportunities for improvement in the management of the condition and its complications, the Rheumatoid Arthritis cost measure represents an opportunity for improvement on overall cost performance. The Rheumatoid Arthritis 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 to 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 5 public comment period,14 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 winsorized15 scaled standardized observed cost to the scaled expected16 cost for all Rheumatoid Arthritis 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 Rheumatoid Arthritis episodes assigned to the clinician across all patients.
Data Sources
The Rheumatoid Arthritis 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)17
Care Settings
The Rheumatoid Arthritis measure focuses on the care provided by clinicians practicing in noninpatient hospital settings for patients with rheumatoid arthritis. The most frequent settings in which a Rheumatoid Arthritis 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 to manage and treat rheumatoid arthritis.
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 Centers for Disease Control and Prevention, “Rheumatoid Arthritis (RA),” 2020, https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html
5 Johnson, K. et al., “Medical Savings of Timely Rheumatoid Arthritis Diagnoses,” Arthritis & Rheumatology 72 (October 2020), https://acrabstracts.org/abstract/medical-savings-of-timely-rheumatoidarthritis-diagnoses/
6 Singh, D. K. et al., “Use of Rheumatologic Testing in Patients Who Eventually Receive a Diagnosis of Rheumatoid Arthritis,” Southern Medical Journal, 112, no. 10, (October 2019): 535-538, https://doi.org/10.14423/smj.0000000000001026
7 Choosing Wisely, “Don’t prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional non-biologic DMARDs),” 2013, https://www.choosingwisely.org/clinician-lists/americancollege-rheumatology-biologics-for-rheumatoid-arthritis/
8 Drosos, A. et al., “Therapeutic Options and Cost-Effectiveness for Rheumatoid Arthritis Treatment,” Current Rheumatology Reports, 22, no. 8 (June 2020): 1-6, https://doi.org/10.1007/s11926-020-00921-8.
9George, M.D. et al., “Variability in glucocorticoid prescribing for rheumatoid arthritis and the influence of provider preference on long-term use,” Arthritis Care & Research 73, no. 11 (July 2020): 1597-1605, https://doi.org/10.1002/acr.24382
10 Black, R.J. et al., “A Survey of Glucocorticoid Adverse Effects and Benefits in Rheumatic Diseases: The Patient Perspective,” Journal of Clinical Rheumatology 23, no. 8 (December 2017): 416-420, https://doi.org/10.1097/rhu.0000000000000585
11Wilson, J.C. et al., “Incidence and Risk of Glucocorticoid-Associated Adverse Effects in Patients With Rheumatoid Arthritis,” Arthritis Care & Research, 71, no. 4, (April 2019): 498-511, https://doi.org/10.1002/acr.23611
12Best, J.H. et al., “Association Between Glucocorticoid Exposure and Healthcare Expenditures for Potential Glucocorticoid-related Adverse Events in Patients with Rheumatoid Arthritis,” Journal of Rheumatology 45, no. 3 (March 2018): 320-328, https://doi.org/10.3899/jrheum.170418
13Bolge, S.C. et al., “Openness to and preference for attributes of biologic therapy prior to initiation among patients with rheumatoid arthritis: patient and rheumatologist perspectives and implications for decision making,” Patient Preference and Adherence 10, (June 2016): 1079-1090, https://doi.org/10.2147/ppa.s107790.
14CMS, “Wave 5 Public Comment Summary”, CMS.gov QPP Cost Measure Information pages, https://www.cms.gov/files/document/wave-5-public-comment-summary-report.pdf
15For information on how costs are winsorized, please refer to Section 4.7.
16Expected 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.
17For information on how LTC MDS data are used in risk adjustment, please refer to Section 4.7.