I need to start with a disclaimer that I have no expertise when it comes to Medicare cost calculations. I am muddling through this by reading the materials on the CMS website. If you have a correction to anything I’ve posted or have better insight, I really want to hear it!
Medicare Spending per Beneficiary (MSPB) is one of the ways that the Center for Medicare and Medicaid Services (CMS) measures whether a given practitioner is providing more costly care than his/her peers. The calculation begins with a list of medical conditions and operations which CMS knows contribute significantly to healthcare spending. Whenever a patient is hospitalized for one of those conditions, it triggers a calculation of MSPB. The episode begins 3 days BEFORE the hospitalization and then continues 30 days after the hospital discharge. The costs of the entire “episode” are attributed to a specific physician.
The illustration below lists the various services is included in an episode. For the most part, wound and hyperbaric services are represented within the spending categories of physician fees and outpatient services. These services contribute at most 19% of the total cost of care in an episode, even if 100% of the physician charges were submitted by the wound care practitioner and 100% of the outpatient charges were related to wound care which is of course, not the case.
What Conditions are Included in the Episodes?
Excluding surgeries, the episode list includes hospitalization for myocardial infarction, congestive heart failure (CHF), urinary tract infections, exacerbation of chronic obstructive pulmonary disease (CODP), GI hemorrhage, ischemic stroke, and pneumonia. Only are a few episodes are relevant to wound care or hyperbaric patients. These include: cellulitis (“all”), cellulitis in diabetics, cellulitis in non-diabetic patients with a wound, cellulitis in obese non-diabetic patients without a wound, and cellulitis “in all other patients” (sic). I think what we take away from this is that CMS worries a lot about hospitalization for cellulitis and if there was ONE THING we could do to help ourselves, it would be to help any patient we are seeing avoid hospitalization for cellulitis. I will keep that in mind the next time I am waffling about putting a patient on antibiotics since, as far as CMS is concerned, if they are hospitalized for cellulitis, it’s on me.
CMS then determines the total cost of care during an episode and compares it to the predicted cost of the episode based on aggregate data. This is part of the process of creating the “value based” payment modifier. Costs are also adjusted for patient level of illness using the Hierarchical Classification Coding (HCC) score about which I have blogged about extensively.
Which Practitioner is Responsible for the Costs?
With all the practitioners involved in the patient’s care during an episode, how does CMS decide who is responsible for the cost of the episode? For Acute Condition episodes, the “most responsible” clinician is the one who billed at least 30% of the inpatient Evaluation and Management (E&M) visits during the trigger event. For Procedural episodes, the “responsible clinician” is the clinician whose Tax Identification Number (TIN) is listed on the claim as having performed the specified operation.
For patients receiving HBOT who are subsequently hospitalized for any reason, the responsible clinician is the practitioner who provided the plurality of visits over the episode. Wound and hyperbaric medicine physicians often see complex patients weekly or even daily. Because of the frequency of a patient’s outpatient visits to the wound or hyperbaric medicine physician, those doctors are being held responsible for the costs associated with the patient’s hospitalization. In other words, if you are treating a diabetic patient who has a heart attack, you are responsible for the costs associated with treating the heart attack.
Key Point: The entire cost of an episode of care is attributed to the doctor who saw the patient most frequently, that is nearly ALWAYS the wound care and hyperbaric medicine practitioner. (It is possible that the new “patient relationship” codes will help with this but it’s not clear how they will be used.)