Table 1

Comparison of the two metrics currently in use for MIPS performance year 2018, and episode-based cost, currently under development by CMS/Acumen LLC31 37 40 41

Medicare spending per beneficiary (MSPB) clinician measureTotal per capita costs for all attributed beneficiaries (TPCC)Episode-based cost measure
CMS definition‘assesses the cost to Medicare of services performed by an individual clinician during an MSPB episode.’
‘compares observed and expected episode costs.’		‘evaluates the overall cost of care provided to beneficiaries attributed to clinicians.’‘the cost to Medicare for the items and services furnished to patients during an episode of care… Episode-based cost measures are developed to inform clinicians on the cost of care for an episode during which they manage the care for an acute medical condition or perform a procedure.’
Numerator‘Sum of the ratio of payment-standardized observed to expected MSPB episode costs for all MSPB episodes for the TIN-NPI or TIN.’‘sum of the annualized, risk-adjusted, specialty-adjusted Medicare Part A and Part B costs across all beneficiaries attributed to a TIN-NPI, within a TIN or TIN-NPI.’Under development.
Denominator‘total number of MSPB episodes for the TIN-NPI or TIN.’‘number of all Medicare beneficiaries who received Medicare-covered services and are attributed to a TIN-NPI, within a TIN or TIN-NPI, during the performance period.’Under development.
StandardizedYesYesYes
Risk-adjustedYesYesYes
Specialty-adjustedYesYesVariable
Reporting period3 days prior to the index admission to 30 days after hospital discharge1 year (anualization of costs)Variable
AttributionPluarity of Part B services during index admissionPCP first (only beneficiaries who received a primary care service during the performance period are considered in attribution)Expected to be variable depending on ‘procedural’, ‘acute inpatient medical condition’ and ‘chronic condition’
Exclusions✓Patient death during window
✓Beneficiaries not enrolled in Medicare part A and B during 93 days prior index through 30 days post discharge
✓The index admission for the episode did not occur in a hospital paid under the Inpatient Prospective Payment System (IPPS)
✓Discharge of the index admission occurred in the last 30 days of the performance period
✓The index admission for the episode is involved in an acute-to-acute hospital transfer
✓The index admission occurs within the 30-day post-discharge period of another MSPB episode
✓The index admission inpatient claim indicates a $0 actual payment or a $0 standardized payment		✓Beneficiaries not enrolled in Medicare part A and B during the performance period
✓Beneficiaries enrolled in a private Medicare health plan for any month during the performance period
✓Beneficiaries resided outside the US during any month of the performance period		✓Depends on the episode group
Level of reportingTIN-NPI or TINTIN-NPI, both within a TIN or TIN-NPITIN-NPI
Legacy (bulk) measuresMedicare spending per beneficiary (MSPB)
Measures the Medicare Part A and Part B costs of care related to inpatient hospital visits
Total per-capita cost for all attributed beneficiaries
Measures all Medicare Part A and Part B costs
Episode measures1. Aortic/mitral valve surgery
2. Cholecystectomy and common duct exploration
3. Colonoscopy
4. Coronary artery bypass graft (CABG)
5. Hip replacement and repair
6. Inpatient hip/femur fracture or dislocation treatment
7. Knee arthroplasty (replacement)
8. Lens and cataract procedures
9. Mastectomy for breast cancer
10. Transurethral resection of the prostate
Episode-based cost measuresSee long list at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/draft-list-of-care-episode-and-patient-condition-groups-and-codes.zip