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episode of care payment

epsd_care_pmt
quality·Updated Jun 23, 2026

Definition

ISO-11179 Definition

The total dollar amount of healthcare expenditure associated with a defined clinical episode spanning from an initiating event through a specified post-acute care period, used as the unit of measurement and payment in bundled payment and episode-based payment models. Episode of care payment methodologies define episode triggers such as a surgical procedure or acute hospitalization, specify the episode window duration typically 90 days post-discharge, identify all clinically related services included in the episode calculation, and establish the target price representing expected efficient care delivery. Variation in episode payment amounts across providers reflects differences in complication rates, readmission rates, post-acute care intensity, and resource utilization during the recovery period.

Healthcare data teams build episode of care measurement systems that attribute claims to episodes using clinical grouping algorithms, calculate all-in episode costs across facility, professional, and post-acute service categories, compare provider episode costs against target prices and peer benchmarks, and identify specific utilization patterns driving high-cost episodes for quality improvement targeting.

Standard Abbreviation

epsd_care_pmt

Category

quality

Production DDL — FACT_QUALITY_MEASURE

FACT_QUALITY_MEASURE.sql
CREATE OR REPLACE TABLE FACT_QUALITY_MEASURE (
    qlty_key        INTEGER        NOT NULL  -- surrogate key,
    mbr_key         INTEGER        NOT NULL  -- FK to DIM_MEMBER,
    plan_key        INTEGER        NOT NULL  -- FK to DIM_PLAN,
    meas_yr         SMALLINT                 -- measurement year,
    hedis_meas_cd   VARCHAR(20)              -- HEDIS measure code,
    denom_ind       CHAR(1)                  -- denominator eligible,
    numer_ind       CHAR(1)                  -- numerator met,
    excl_ind        CHAR(1)                  -- exclusion indicator,
    gap_open_ind    CHAR(1)                  -- care gap open,
    star_rtg_nbr    DECIMAL(3,1)             -- star rating,
    qlty_scr        DECIMAL(5,2)             -- quality score,
    perf_thrsh_pct  DECIMAL(5,2)             -- performance threshold,
    raf_scr         DECIMAL(10,3)            -- risk adjustment factor,
    outreach_cnt    SMALLINT                 -- outreach attempts,
    load_dt         TIMESTAMP_NTZ  NOT NULL  -- load timestamp
);

Standard Snowflake DDL for the canonical quality table. Convert to BigQuery or Databricks →

Why This Term Matters

Quality measure data determines how payers and providers are rated and reimbursed under CMS Stars, HEDIS, and value-based care contracts. Data engineers who understand quality terminology build measure calculation pipelines that correctly attribute patients, apply denominator exclusions, and flag documentation gaps before submission deadlines. Incorrect quality data directly affects star ratings, pay-for-performance bonuses, and Medicare Advantage plan bids.

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