HPC Corner: Cost of Care Measures

HPC Corner: Cost of Care Measures
By: David Seidenwurm, MD, FACR

Value in healthcare is defined as quality of outcomes per unit cost, just as we define the value of transportation as safe, comfortable, timely miles traveled per unit cost or the value of art as ineffable experience. The evident failure of these analogies reveals some of the complexity in measuring the value of healthcare. And, there is further difficulty in diagnostic or interventional practices that are often more than one step removed from hard outcomes like morbidity and mortality. The difficulty of measuring medical quality has led to a proliferation of metrics that have reflected quality as perceived by professionals and patients with varying success.

Measuring the cost of care (COC) that reflects value in healthcare is no less challenging. Simply totaling up the bills won’t work, since charges do not reflect payments reliably. Adding up payments won’t work, since payments reflect sources of insurance and vagaries of local or regional markets, even in government programs with uniform methods, because geographic and other adjustments are applied. Also, even in fully capitated risk-based programs, internal allocations are arbitrary, so actual medical expenditures are hard to isolate.

To meet these challenges and give value the emphasis demanded by society, CMS and other payers have embarked upon several projects designed to reflect costs accurately and fairly. Obstacles include defining comparable populations by diagnosis, procedure, or symptom, and attributing costs to the disorders or episodes themselves. It can be quite challenging to name the primary professionals involved accurately. The precise methods for adjusting the costs to reflect differences among patients based upon their individual risk factors, preferences and ability to participate actively in their own care are controversial. It is also important to define minimum sample sizes and appropriate benchmark populations so clinicians can be compared fairly.

Each of these factors must be considered in the development of a COC metric, and scientific investigation as well as real world data analyses are required to ensure that metrics included in payment or public disclosure programs meet rigorous standards. One can easily imagine unintended adverse consequences that might ensue if diagnoses, episode triggers and time lines, included and excluded services, and responsible clinicians are improperly defined. Selection of the correct severity adjustment method is critical to ensure that risky patients are not denied medically necessary services because of unfavorable outcome or cost profiles.

Under current proposals, neuroscience clinicians will be subject to COC metrics as part of care teams for Intracranial Hemorrhage or Cerebral Infarction either directly or indirectly. Depending upon the practice structure, neuroradiology compensation could be affected through payments within multi-specialty or faculty practice groups, or indirectly through alterations in referral patterns as unwarranted, redundant or wasteful use of resources is curtailed. The Total Cost of Care metric for primary care may indirectly affect radiologists depending upon the compensation formula of multi-specialty groups, hospital employees or faculty practice plans. The same is also true of the Medicare Spending per Beneficiary metric. These will be reported in the coming years and payment adjustments will occur. A spine surgery COC metric is also undergoing preliminary testing.

In order to help ensure the clinical validity of cost of care metrics attributable at the level of the clinician, several ASNR members have played important roles in the measure development and testing.

Thanks to Josh Hirsch and Greg Nicola for their leadership in this arena!


  1. Porter ME. What is value in health care? N Engl J Med 2010;363:2477—81, 10.1056/NEJMp1011024.
  2. Spilberg G, Nicola GN, Rosenkrantz AB, et al. Understanding the impact of ‘cost’ under MACRA: a neurointerventional imperative! J Neurointervent Surg 2018;10:1005—11, 10.1136/neurintsurg-2018-013972.
  3. 2018 Merit-based incentive payment system (MIPS) cost performance category fact sheet. https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Cost-Performance-Category-Fact-Sheet.pdf.
  4. Medicare resource use measurement plan. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/ResourceUse_Roadmap_OEA_1-15_508.pdf.

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