Hospital-level, risk-standardized payment associated with a 30-day episode-of-care for heart failure (HF)

HF is a common condition in the elderly with substantial variability in payments due to different practice patterns. Quality measures for HF such as 30-day HF risk-standardized mortality rate (RSMR) are already publicly reported. In the context of its publicly reported quality measures, HF is an ideal condition in which to assess payments for Medicare patients and relative hospital value. Therefore, we created a measure of payments for a 30-day episode of care for HF that is aligned with CMS’s 30-day AMI mortality and readmission measures, making it possible for CMS to assess the value of care provided for these episodes.
The measure uses Condition Categories (CCs) to adjust for patient case-mix across hospitals. Details of our risk-adjustment strategy can be found in our technical report at https://www.qualitynet.org/inpatient/measures/payment/methodology.

This measure is for patients who are admitted with HF. We determine this by examining the principal discharge diagnosis code in the administrative data. If a patient has a principal discharge diagnosis of any other condition, even if this includes a secondary diagnosis of HF, this admission is not considered as an index admission. Therefore, the concurrency of clinical events is not applicable for this measure. However, the model does risk adjust for comorbidities listed in outpatient and inpatient claims in the 12 months prior to the index admission as well as the secondary diagnoses included in the index admission that are not considered complications of care.