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Medicare seeking input on eight draft episode cost measures

Medicare seeking input on eight draft episode cost measures

October 17, 2017

In an important step toward the use of episode-based cost measures in Medicare, the Centers of Medicare and Medicaid Services (CMS) is pilot testing eight new measures that it expects to use in the future to determine physician scores in the cost component of the Medicare Incentive-Based Payment System (MIPS). Unlike most of the earlier episode cost measures that CMS has published for comment, these eight measures have had significant clinical input from physicians and other health professionals. The measures involve percutaneous coronary intervention, knee arthroplasty, cataract removal, lower limb revascularization, colonoscopy, intracranial hemorrhage, and pneumonia.

For the pilot test, feedback reports based on claims data from June 1, 2016 to May 31, 2017 have been compiled for any physician and/or group with a 10-episode case minimum on at least one of the eight episode measures. All told, 48,263 individual physicians and 17,557 TIN-level groups met the criteria. Acumen, LLC, the CMS contractor developing the measures, has contacted all physicians and groups for which CMS had e-mail addresses to ask that they review their reports and complete a survey (online survey) that addresses both the report and the measures. Measure specifications and a mock report will be posted on the CMS web site ( ) so that others can also complete the survey and provide feedback that will be used to refine the measures prior to their use in MIPS. For now, the reports are informational only but because it is very likely that these measures will be used to create MIPS cost scores in the future, it is important that physicians take time to review and offer feedback during the pilot which will run from October 16 through November 15.

For general information please go to:

Over the past year, CMS posted and asked for comments on 119 episode cost measures. In general, commenters, including the AMA, found the concept of episode measures preferable to the two total cost measures that had been carried over from the value-based modifier. However, the proposed measures were criticized as having significant errors and inadequate clinical input. In response, CMS agreed not to count costs in the MIPS score for 2017 and has proposed to continue this policy in 2018. Acumen was directed to create a process that would involve more clinical input throughout the episode development process and responded by creating clinical subcommittees to review, revise, or replace the earlier episodes. The plan is to work in waves so developers can learn as they go. 

Eventually Acumen expects to run at least 18 clinical subcommittees each addressing different areas of care. The initial work is focused on acute inpatient conditions and procedures. Work on chronic care measures, which is expected to be more difficult, will follow. Seven subcommittees, composed of 147 members affiliated with 98 physician and other professional organizations, have been working since late May to review previously developed measures and public comments relevant to their area of care. Each selected or developed one or two measures for the initial test and then worked through a number of decision points, including codes that would trigger the episode, other codes to be included, length of the episode, patients to be excluded, potential subgroups and risk adjustment. The survey contains questions addressing specific features of the measure as well as the format for the report. Respondents do not have to answer each question.  It is also possible to attach a document in addition to or instead of completing the survey.

The specific measures are:

  • Elective Outpatient Percutaneous Coronary Intervention (PCI)
  • Knee Arthroplasty
  • Routine Cataract Removal with Intraocular Lens (IOL) Implantation
  • Revascularization for Lower Extremity Chronic Critical Limb Ischemia
  • Screening/Surveillance Colonoscopy
  • Intracranial Hemorrhage or Cerebral Infarction
  • Simple Pneumonia with Hospitalization
  • ST-Elevation Myocardial Infarction (STEMI) with PCI

The field test reports for group practices and solo practitioners will be distributed through the CMS Enterprise Portal which CMS has used in the past for distributing Quality and Resource Use Reports (QRURs).  The field test reports are separate from the 2016 QRURs, which were made available in mid-September. Obtaining a report requires an EIDM account with access to “Physician Quality and Value Programs.” Many groups have designated individuals who already have this access and will be able to retrieve an aggregate group report as well as the reports for individual physicians within the group.  Individual physicians who prefer may access their own report directly if they go through the process of acquiring the required EIDM account. Those who do not already have an EIDM account can set one up and get access to a “Physician Quality and Value Programs” role by using this guide.

To sign up for one of the two National Provider Calls that will be held on the field test, click on one of the links below:

Monday, October 30 at 12:00-1:30 PM ET
Thursday, November 2 at 3:30-5:00 PM ET


Terri Marchiori
Director, Federation Relations
American Medical Association


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