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An Administrative Claims Measure of Payments Made for Medicare Patients for a 30-Day Episode of Care for Acute Myocardial Infarction

Kim, Nancy, MD, PhD*,†; Bernheim, Susannah M., MD, MHS*,†; Ott, Lesli S., MA*; Han, Lein, PhD; Spivack, Steven B., MPH*; Xu, Xiao, PhD*,§; Volpe, Mark, BS*,∥; Liu, Alex, BS*,¶; Krumholz, Harlan M., MD, SM*,#,**,††

doi: 10.1097/MLR.0000000000000361
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Background: Understanding both cost and quality across institutions is a critical first step to illuminating the value of care purchased by Medicare. Under contract with the Centers for Medicare and Medicaid Services, we developed a method for profiling hospitals by 30-day episode-of-care costs (payments for Medicare beneficiaries) for acute myocardial infarction (AMI).

Methods: We developed a hierarchical generalized linear regression model to calculate hospital risk-standardized payment (RSP) for a 30-day episode for AMI. Using 2008 Medicare claims, we identified hospitalizations for patients 65 years of age or older with a discharge diagnosis of ICD-9 codes 410.xx. We defined an AMI episode as the date of admission plus 30 days. To reflect clinical care, we omitted or averaged payment adjustments for geographic factors and policy initiatives. We risk-adjusted for clinical variables identified in the 12 months preceding and including the AMI hospitalization. Using combined 2008–2009 data, we assessed measure reliability using an intraclass correlation coefficient and calculated the final RSP.

Results: The final model included 30 variables and resulted in predictive ratios (average predicted payment/average total payment) close to 1. The intraclass correlation coefficient score was 0.79. Across 2382 hospitals with ≥25 hospitalizations, the unadjusted mean payment was $20,324 ranging from $11,089 to $41,897. The mean RSP was $21,125 ranging from $13,909 to $28,979.

Conclusions: This study introduces a claims-based measure of RSP for an AMI 30-day episode of care. The RSP varies among hospitals, with a 2-fold range in payments. When combined with quality measures, this payment measure will help profile high-value care.

*Center for Outcomes Research and Evaluation, Yale-New Haven Hospital

Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT

Centers for Medicare & Medicaid Services, Baltimore, MD

§Department of Obstetrics, Gynecology and Reproductive Sciences

Physician Associate Program, Yale University School of Medicine, New Haven, CT

Cipher Health, New York, NY

#Section of Cardiovascular Medicine

**Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine

††Department of Health Policy and Administration, Yale School of Public Health, New Haven, CT

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The analyses on which this publication is based were performed under contract HHSM-500-2008-0025I/HHSM-500-T0001, Modification No. 000008, entitled “Measure Instrument Development and Support,” funded by CMS, an agency of the US Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented.

H.M.K. and X.X. are supported by grant U01 HL105270-04 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute. H.M.K. also reports that he is the recipient of the following grants: a research grant from Medtronic through Yale University; grant R01 HS016929-02 from the Agency for Healthcare Research and Quality and the United Health Foundation; and grant 20070407 from The Commonwealth Fund.

The funding sponsors had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or preparation of the manuscript. The CMS reviewed and approved the use of its data for this work and approved submission of the manuscript.

N.K., S.M.B., L.S.O., S.B.S., X.X., M.V., A.L., and H.M.K. report that they receive contract funding from CMS to develop and maintain quality measures. H.M.K. reports that he is a consultant to UnitedHealthcare. The remaining authors declare no conflict of interest.

Reprints: Nancy Kim, MD, PhD, 1 Church Street, Suite 200, New Haven, CT 06510. E-mail: nancy.kim@yale.edu.

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