ETG Based PNEUMONIA cost of care measure

The measure focuses on resources used to deliver episodes of care for patients with pneumonia. Pneumonia episodes are defined using the Episode Treatment Groups (ETG) methodology and describe the unique presence of the condition for a patient and the services involved in diagnosing, managing and treating pneumonia. A number of resource use measures are defined for pneumonia episodes, including overall cost of care, cost of care by type of service, and the utilization of specific types of services. Each resource use measure is expressed as a cost or a utilization count per episode and comparisons with internal and external benchmarks are made using risk adjustment to support valid comparisons.
As requested by NQF, the focus of this submission is for pneumonia episodes and will cover both measures at the pneumonia base and severity level and also a pneumonia composite measure where pneumonia episode results are combined across pneumonia severity levels. At the most detailed level, the measure is defined as the base condition of pneumonia and an assigned level of severity (e.g., resources per episode for pneumonia, severity level 1 episodes). Composite measures can then be created using these measurement units to meet a specific need. For example, a composite measure for pneumonia is derived by combining pneumonia episode results across pneumonia severity levels. Appropriate risk adjustment is applied to support comparisons (e.g., for physician measurement, adjusting for a physician’s mix of pneumonia episodes by severity level when supporting a pneumonia composite comparison).

The focus of this measure is on pneumonia. However, pneumonia episode results could also be included in a “pulmonary” or other clinical composite for a physician, combining episodes in clinical areas similar to pneumonia. Further, an “overall” composite for a physician can be created, again by aggregating episode results across appropriate conditions and severity levels and applying proper risk adjustment when making comparisons.