When developing cost and resource use measures, specifications should include the types of required data, the time periods relevant to the measures, and which patients, procedures, or conditions to include in the measurement. For example, if the measure carves out specific services from the claims for certain health plans and not for others, comparison of costs among the plans could be misleading. Most cost and resource use measures use claims data. Varying coding practices can compromise data reliability and validity. It is best to try and address these issues during measure development and maintenance.

To assess resource use in health care fully, it is important to consider measures with different units of analysis:

• per capita-population and per capita-patient
• per encounter
• per admission
• per procedure
• per visit

Each unit of analysis provides a different lens for viewing resource use and helps determine where measured entities can make improvements and contributes to developing the clinical logic.

MEASURE CLINICAL LOGIC

The measure developer should identify cost and resource use measures for acute conditions, chronic conditions, procedures, or preventive services. This identification often affects the clinical logic. The design of the analytic steps creates appropriately homogeneous units for measurement.

Measure Construction Logic

Time Intervals

The measure developer should specify when to start or end a measurement period for each measure. They identify these time intervals through clinical or evidence-based guidelines, expert opinion, or empirical data. Typically, the time interval for measure reporting is the calendar year.

Assigning and Triaging Claims

Some examples of considerations in the use of claims data include

• how to use different claims providing information for the same event—especially those resulting in an inflation of resource use amounts
• when and how to map or feed claims from different sources into the same measure
• when and which services may pass other services
• how to identify units of resource use

The measure developer will identify and define the units of health services or resource use units. Measure specifications must clearly define and provide detailed instructions on how to identify a single health service unit, including the relevant codes, modifiers, or approaches to identify the amount.

Adjusting for Comparability

Define Risk Adjustment Approach

Risk adjustment reduces negative or positive consequences associated with caring for patients of higher or lower health risk or propensity to require health services. Resource use measures, including episode-based measures, generally risk-adjust as part of the steps to address differences in patient characteristics and disease severity or stage.

Define Stratification Approach

Another type of adjustment is stratification, which is important if known gaps of care exist or if there is a need to expose differences in results so interested parties can take appropriate action. In addition to exposing gaps of care, a measure may specify stratification of results within a major clinical category (e.g., diabetes) by severity or other clinical differences.

Define Costing Methodology

Measure developers should use different costing methods, depending on the intended perspective:

• count of services*
• actual amount paid
• standardized prices

*Depending on the intended use and requirement of each program, the classification of measures using this methodology may be as a quality measure.