Dataset Information

Development and Testing of Improved Models to Predict Payment Using Centers for Medicare & Medicaid Services Claims Data.

ABSTRACT:

Importance

Predicting payments for particular conditions or populations is essential for research, benchmarking, public reporting, and calculations for population-based programs. Centers for Medicare & Medicaid Services (CMS) models often group codes into disease categories, but using single, rather than grouped, diagnostic codes and leveraging present on admission (POA) codes may enhance these models.

Objective

To determine whether changes to the candidate variables in CMS models would improve risk models predicting patient total payment within 30 days of hospitalization for acute myocardial infarction (AMI), heart failure (HF), and pneumonia.

Design, setting, and participants

This comparative effectiveness research study used data from Medicare fee-for-service hospitalizations for AMI, HF, and pneumonia at acute care hospitals from July 1, 2013, through September 30, 2015. Payments across multiple care settings, services, and supplies were included and adjusted for geographic and policy variations, corrected for inflation, and winsorized. The same data source was used but varied for the candidate variables and their selection, and the method used by CMS for public reporting that used grouped codes was compared with variations that used POA codes and single diagnostic codes. Combinations of use of POA codes, separation of index admission diagnoses from those in the previous 12 months, and use of individual International Classification of Diseases, Ninth Revision, Clinical Modification codes instead of grouped diagnostic categories were tested. Data analysis was performed from December 4, 2017, to June 10, 2019.

Main outcomes and measures

The models' goodness of fit was compared using root mean square error (RMSE) and the McFadden pseudo R2.

Results

Among the 1?943?049 total hospitalizations of the study participants, 343?116 admissions were for AMI (52.5% male; 37.4% aged ?74 years), 677?044 for HF (45.5% male; 25.9% aged ?74 years), and 922?889 for pneumonia (46.4% male; 28.2% aged ?74 years). The mean (SD) 30-day payment was $23?103 ($18?221) for AMI, $16?365 ($12?527) for HF, and $17?097 ($12?087) for pneumonia. Each incremental model change improved the pseudo R2 and RMSE. Incorporating all 3 changes improved the pseudo R2 of the patient-level models from 0.077 to 0.129 for AMI, from 0.042 to 0.129 for HF, and from 0.114 to 0.237 for pneumonia. Parallel improvements in RMSE were found for all 3 conditions.

Conclusions and relevance

Leveraging POA codes, separating index from previous diagnoses, and using single diagnostic codes improved payment models. Better models can potentially improve research, benchmarking, public reporting, and calculations for population-based programs.

SUBMITTER: Krumholz HM

PROVIDER: S-EPMC6694388 | biostudies-literature | 2019 Aug

REPOSITORIES: biostudies-literature

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Publications

Development and Testing of Improved Models to Predict Payment Using Centers for Medicare & Medicaid Services Claims Data.

Krumholz Harlan M HM Warner Frederick F Coppi Andreas A Triche Elizabeth W EW Li Shu-Xia SX Mahajan Shiwani S Li Yixin Y Bernheim Susannah M SM Grady Jacqueline J Dorsey Karen K Desai Nihar R NR Lin Zhenqiu Z Normand Sharon-Lise T ST

JAMA network open 20190802 8

<h4>Importance</h4>Predicting payments for particular conditions or populations is essential for research, benchmarking, public reporting, and calculations for population-based programs. Centers for Medicare & Medicaid Services (CMS) models often group codes into disease categories, but using single, rather than grouped, diagnostic codes and leveraging present on admission (POA) codes may enhance these models.<h4>Objective</h4>To determine whether changes to the candidate variables in CMS models ...[more]

PMID: 31411709

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Dataset Information

Development and Testing of Improved Models to Predict Payment Using Centers for Medicare & Medicaid Services Claims Data.

Importance

Objective

Design, setting, and participants

Main outcomes and measures

Results

Conclusions and relevance

Publications

Development and Testing of Improved Models to Predict Payment Using Centers for Medicare & Medicaid Services Claims Data.

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