MEDICARE

Certain Physician 

Feedback Reporting 

Practices of Private 

Entities Could 

Improve CMS’s 

Efforts

Report to Congressional Committees

March 2014

GAO-14-279

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-279, a report to 

congressional committees

March 2014

MEDICARE

Certain Physician Feedback Reporting Practices of 

Private Entities Could Improve CMS’s Efforts

Why GAO Did This Study

Health care payers—including 

Medicare—are increasingly using VBP 

to reward the quality and efficiency 

instead of just the volume of care 

delivered. Both traditional and newer 

delivery models use this approach to 

incentivize providers to improve their 

performance. Feedback reports serve 

to inform providers of their results on 

various measures relative to 

established targets. The American 

Taxpayer Relief Act of 2012 mandated 

that GAO compare private entity and 

Medicare performance feedback 

reporting activities. 

GAO examined (1) how and when 

private entities report performance 

data to physicians, and what 

information they report; and (2) how 

the timing and approach CMS uses to 

report performance data compare to 

that of private entities. GAO contacted 

nine entities—health insurers and 

statewide collaboratives—recognized 

for their performance reporting 

programs. Focusing on physician 

feedback, GAO obtained information 

regarding report recipients, data 

sources used, types of performance 

measures and benchmarks, frequency 

of reporting, and efforts to enhance the 

utility of performance reports. GAO 

obtained similar information from CMS 

about its Medicare feedback efforts.

What GAO Recommends

The Administrator of CMS should 

consider expanding performance 

benchmarks to include state or 

regional averages, and disseminating 

feedback reports more frequently than 

the current annual distribution.

What GAO Found

Private entities GAO reviewed for this study selected a range of measures and 

benchmarks to assess physician group performance, and provided feedback 

reports to physicians more than once a year. Private entities almost exclusively 

focused their feedback efforts on primary care physician groups participating in 

medical homes and accountable care organizations, which hold physicians 

responsible for the quality and cost of all services provided. They limited their 

feedback reporting to those with a sufficient number of enrollees to ensure the 

reliability of reported measures. The entities decided on the number and type of 

measures for their reports, and compared each group’s performance to multiple 

benchmarks, including peer group averages or past performance. All the entities 

used quality measures, and some also used utilization or cost measures. 

Because of the variety of quality measures and benchmarks, feedback report 

content differed across the entities. Some entities noted that in addition to 

national benchmarks, they compared results to state or regional level rates to 

reflect local patterns of care which may be more relevant to their physicians. 

Most health insurers spent from 4 to 6 months to generate their performance 

reports, a period that allowed them to amass claims data as well as to make 

adjustments and perform checks on the measure calculations. Commonly, 

private entities issued interim feedback reports, covering a 1-year measurement 

period, on a rolling monthly, quarterly, or semiannual schedule. They told GAO 

that physicians valued frequent feedback in order to make changes that could 

result in better performance at the end of the measurement period.

Feedback from the Centers for Medicare & Medicaid Services (CMS) included 

quality measures determined by each medical group, along with comparison to 

only one benchmark, and CMS did not provide interim reports to physicians. The 

agency has phased in performance feedback in order to meet its mandate to 

apply value-based payment (VBP) to all physicians in Medicare by 2017, a 

challenge not faced by private entities. In September 2013, CMS made feedback 

reports available to 6,779 physician groups. While private entities in this study 

chose the measures for their reports, CMS tied the selection of specific quality 

measures to groups’ chosen method of submitting performance data. Although 

both CMS and private entities focused their feedback on preventive care and 

management of specific diseases, CMS’s reports contained more information on 

costs and outcomes than some entities. While private entities employed multiple 

benchmarks, the agency only compared each group’s results to the national 

average rates of all physician groups that submitted data on any given measure. 

CMS’s use of a single benchmark precludes physicians from viewing their 

performance in fuller context, such as relative to their peers in the same 

geographic areas. CMS’s report generation process took 9 months to complete, 

several months longer than health insurers in the study, although it included 

more steps. In contrast to private entity reporting, CMS sent its feedback report 

to physicians once a year, a frequency that may limit physicians’ opportunity to 

make improvements in advance of their annual payment adjustments.

The Department of Health and Human Services generally concurred with GAO’s 

recommendations and asked for additional information pertaining to the potential 

value of using multiple benchmarks to assess Medicare physicians’ performance.

View GAO-14-279. For more information, 

contact James Cosgrove at (202) 512-7114 or 

cosgrovej@gao.gov.
Page i GAO-14-279 Medicare Provider Feedback

Letter 1 

Background 5

Private Entities Selected a Range of Measures and Benchmarks 

to Assess Physician Group Performance, and Provided 

Feedback More than Once a Year 8

CMS Feedback Included Group-Determined Physician Quality 

Measures and Only One Benchmark; CMS Issued Reports 

Less Frequently than Private Entities 22

Conclusions 31

Recommendations for Executive Action 32

Agency Comments and Our Evaluation 33

Appendix I Private Entity and Medicare Performance Feedback for Hospitals 35

Appendix II Quality Measures Used in Sample Physician Feedback Reports 

Provided by Selected Private Entities 39

Appendix III Comments from the Department of Health and Human Services 40

Appendix IV GAO Contact and Staff Acknowledgments 44

Related GAO Products 45

Tables

Table 1: Key Features of Hospital Feedback Reporting by 

Selected Private Entities and CMS 37

Table 2: Number of Quality Measures Categorized by Type Found 

in Sample Physician Feedback Reports Provided by 

Selected Private Entities 39

Contents
Page ii GAO-14-279 Medicare Provider Feedback

Figures

Figure 1: CMS’s Phased Approach to Providing Value Modifier 

(VM) Reports to Eligible Professionals (EP) 7

Figure 2: Private Entity Examples of Hemoglobin A1C Measures 

as Presented in Four Sample Reports 13

Figure 3: Private Entity’s Display of Information on Specialty 

Referral Patterns in a Sample Report 15

Figure 4: Private Entity Examples of Emergency Department (ED) 

Visit Measures as Presented in Two Sample Reports 16

Figure 5: Private Entity Examples of Benchmark Comparisons as 

Presented in Three Sample Reports 17

Figure 6: Illustration of Timelines to Report Production for Health 

Insurers and Statewide Health Care Collaboratives 19

Figure 7: Cost Measures Displayed in CMS’s 2013 Quality and 

Resource Use Reports 25

Figure 8: Performance Benchmarks Displayed in CMS’s 2013 

Quality and Resource Use Reports 26

Figure 9: CMS Sample Composite Scores, Quality Tier, and Value 

Modifier 28

Figure 10: Report Generation Timeline for CMS Performance

Feedback Reports, September 2013 30
Page iii GAO-14-279 Medicare Provider Feedback

Abbreviations

ABC Achievable Benchmark of Care

ACO accountable care organization

ACSC Ambulatory Care Sensitive Condition

CAH critical access hospital

CMS Centers for Medicare & Medicaid Services

COPD chronic obstructive pulmonary disease

EHR electronic health record

EP eligible professional

FFS fee-for-service 

HHS Department of Health and Human Services

PQRS Physician Quality Reporting System

QRUR Quality and Resource Use Reports

VBP value-based payment

VM Value Modifier

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Page 1 GAO-14-279 Medicare Provider Feedback

441 G St. N.W.

Washington, DC 20548

March 26, 2014

The Honorable Ron Wyden

Chairman

The Honorable Orrin G. Hatch

Ranking Member

Committee on Finance

United States Senate

The Honorable Fred Upton

Chairman

The Honorable Henry Waxman

Ranking Member

Committee on Energy and Commerce

House of Representatives

The Honorable Dave Camp

Chairman

The Honorable Sander Levin

Ranking Member

Committee on Ways and Means

House of Representatives

Increasingly, health care payers—including Medicare—are rethinking the 

way they reimburse providers in an attempt to shift away from paying 

solely for the volume of care delivered and toward paying them for the 

value of their care. One such approach—known as value-based payment 

(VBP)—links a portion of physician compensation to achieving specified 

levels of performance. VBP can be used as a means to improving quality 

and efficiency in the traditional health care delivery environment by 

encouraging providers to address gaps in patient care and consider the 

likely costs and benefits of care. It can also be used with newer care 

delivery models, such as accountable care organizations (ACO) and 
 

Page 2 GAO-14-279 Medicare Provider Feedback

patient-centered medical homes.1

While physicians and other providers may intend to furnish consistently 

high-quality, efficient care, they may not always know how well they do or 

where practice changes are needed. Therefore, a key element of the VBP 

approach is for payers to develop performance feedback reports to 

indicate specific opportunities for improvement.

Under these arrangements, payers 

hold teams of providers responsible for all of a patient’s care. They 

reward those who coordinate services across providers and make costeffective referral decisions, among other practices.

2 Performance feedback 

entails collecting data on measures of quality and cost of care, assessing 

performance against benchmarks, and communicating results to 

providers. For example, periodic feedback reports can make providers 

aware of the percentage of their patients receiving appropriate screening 

tests, or those with potentially avoidable emergency department visits. 

The expectation is that giving detailed, timely feedback to providers will 

enhance their ability to take actions that improve performance.3

The American Taxpayer Relief Act of 2012 mandated that GAO compare 

how private entities and the Centers for Medicare & Medicaid Services 

(CMS)—the agency within the Department of Health and Human Services 

(HHS) that administers the Medicare program—conduct performance 

feedback reporting for health care providers.4

 

1

In an ACO, groups of physicians and hospitals share responsibility for providing care to a 

designated group of patients, and financial risk. Payers generally require providers to 

meet predetermined performance targets on quality and cost in order to share in savings 

or receive other incentives. Medical homes allow physicians to earn incentives for 

reducing utilization of high-cost settings, such as emergency departments and hospitals, 

through care coordination activities. Medical homes unite physicians of various specialties, 

especially targeting patients with chronic illnesses.

To meet this requirement, 

2

Private feedback reports are generally designed to identify differences between 

providers’ current practices and desired performance and may be combined with financial 

incentives to encourage improvement. Other performance reporting makes provider 

information available to the public through recognition programs or websites, thus using 

professional reputation to promote high-quality care. In this report, performance feedback 

reports refer to the private reports sent to providers from a payer or other entity.

3

How well this approach will work is still unclear. Experts have noted that the evidence of 

VBP’s effectiveness is limited. Proponents of VBP contend that, with sufficient financial 

incentive, VBP can improve overall quality of care and promote efficient practice patterns. 

However, critics assert that fundamental issues, such as developing appropriate 

performance measures for all provider types, have not yet been adequately addressed.

4

Pub. L. No. 112-240, § 609(b)(5), 126 Stat. 2313, 2350 (Jan. 2, 2013).
 

Page 3 GAO-14-279 Medicare Provider Feedback

we conducted briefings for congressional staff on our preliminary findings 

in September 2013. This report contains information we provided during 

those briefings, updated with additional information, addressing

1. how and when private entities—such as health insurers—report 

performance data to physicians, and what information they report; and

2. how the timing and approach CMS uses to report performance data to 

physicians compare to that of private entities.

In addition, appendix I contains information on how private entities and

Medicare provide performance feedback to hospitals.

To examine how and when private entities report performance data to 

physicians, and to identify what information they provide, we contacted 

nine private entities that had experience with VBP programs or that had 

innovative features in their performance feedback programs. To make our 

selection, we asked representatives of America’s Health Insurance 

Plans,5 Blue Cross Blue Shield Association,6 and Network for Regional 

Healthcare Improvement to suggest leading organizations that met those 

criteria.7 We also considered programs profiled in peer-reviewed 

literature, as well as those operating in varying geographic areas across 

the country. We chose six health insurers, and three statewide health 

care collaboratives—organizations comprising providers, payers, and 

employers that focus on quality improvement activities—as follows:8

• Aetna

 

5

America’s Health Insurance Plans is an industry trade association representing private 

entities that provide health insurance coverage through employers, the individual market, 

and public programs.

6

Blue Cross and Blue Shield Association coordinates legislative, regulatory, and political 

strategy on behalf of a nationwide group of 37 independent, locally operated insurance

companies.

7

Network for Regional Healthcare Improvement represents health care collaboratives at 

the city, state, and regional level that provide programs for over 110 million Americans. It 

brings together multiple stakeholders—physicians, hospitals, health insurers, and 

employers—to address various health care topics, including performance measurement 

and payment and delivery system reform.

8

Nearly all of our selected entities reported to physicians on their performance. One 

private entity only reported to hospitals on performance, and is included in appendix I.
 

Page 4 GAO-14-279 Medicare Provider Feedback

• Blue Shield of California

• Blue Cross and Blue Shield of Florida, Inc.

• Highmark Blue Cross Blue Shield

• Horizon Blue Cross Blue Shield of New Jersey

• Iowa Healthcare Collaborative

• Maine Health Management Coalition

• Oregon Health Care Quality Corporation

• WellPoint

We interviewed representatives of these private entities regarding the 

feedback report recipients, data sources used, types of performance 

measures and benchmarks, frequency of reporting, and efforts to 

enhance the utility of their performance reports. We also requested 

sample physician feedback reports to learn how the data were presented. 

In some cases, entities had multiple performance reporting initiatives. We 

focused on the reports that were most similar to the type of reporting to 

physicians that CMS provided to medical groups.

Our findings regarding private entity performance reporting to physicians 

are limited to the entities we interviewed and cannot be generalized to 

other health insurers and health care collaboratives. In this report, we 

describe private entities’ feedback programs in operation in 2013, 

although performance reporting continues to evolve as organizations

adopt newer payment and delivery models. We did not evaluate the 

effectiveness of the feedback in altering physician practice patterns. Also, 

we did not gather information on the payment incentives, if any, 

associated with these entities’ reporting initiatives, as that issue was 

beyond our scope.9

 

9

We reported on physician payment incentives in 2012. See GAO, Medicare Physician 

Payment: Private-Sector Initiatives Can Help Inform CMS Quality and Efficiency Incentive 

Efforts, 

Because nationwide interest in VBP has been largely 

aimed at physician care, we primarily focused our review on performance 

reporting to physicians, and as noted, present additional information on 

GAO-13-160 (Washington, D.C.: Dec. 26, 2012).
 

Page 5 GAO-14-279 Medicare Provider Feedback

our methodology and findings related to hospital feedback reporting in 

appendix I.10

To learn how the timing and approach CMS uses to report performance 

data to physicians compare to that of private entities, we obtained CMS 

documentation similar to that received from the selected entities. We 

analyzed information regarding CMS report recipients, data sources used, 

types of performance measures and benchmarks, frequency of reporting, 

and efforts to enhance the utility of the reports. We also examined a 

prototype of the report CMS provided to physicians in September 2013. 

We spoke with CMS officials about their report preparation process and 

about components of the feedback program that differ from those of 

private entities.

We conducted this performance audit from April 2013 to March 2014 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

Laws enacted since 2006 have directed CMS to collect performance 

information on providers and eventually reward quality and efficiency of 

care rather than reimburse for volume of services alone.

• The Tax Relief and Health Care Act of 2006 required the 

establishment of the Physician Quality Reporting System (PQRS) to 

encourage physicians to successfully report data needed for certain 

quality measures.11 PQRS applies payment adjustments to promote 

reporting by eligible Medicare professionals (EP)—including 

physicians, nurses, physical therapists, and others.12

 

10CMS also includes other types of providers, such as long-term care hospitals, under 

separate VBP programs. These programs are not included in our scope because private 

entities typically do not have reporting programs for such provider types.

In 2013, EPs 

11Pub. L. No. 109-432, § 101(b), 120 Stat. 2922, 2975 (Dec. 20, 2006).

12Through 2014, CMS plans to provide an upward payment adjustment to physicians who 

satisfactorily report quality data. In 2015, groups that do not satisfactorily report data are 

to be subject to a downward percentage payment adjustment.

Background
 

Page 6 GAO-14-279 Medicare Provider Feedback

could report data to PQRS using claims, electronic health records 

(EHR)13 or a qualified registry,14

• The Medicare Improvements for Patients and Providers Act of 2008 

established the Physician Feedback Program, under which CMS was 

required, beginning in 2009, to distribute confidential feedback 

reports, known as Quality and Resource Use Reports (QRUR), to 

show physicians their performance on quality and cost measures.

or opt for CMS to calculate quality 

measures using administrative claims data. Under its group practice 

reporting option, CMS allows EPs to report to PQRS as a group, 

either through a registry or a web-based interface.

15

• The Patient Protection and Affordable Care Act required HHS to 

coordinate the Physician Feedback Program with a Value Modifier 

(VM) that will adjust fee-for-service (FFS) physician payments for the 

relative quality and cost of care provided to beneficiaries.16

As required by law, CMS implemented a performance feedback program 

for Medicare physicians, which serves as the basis for eventual payment 

adjustments. (See fig. 1.)

In 

implementing the VM, CMS’s Center for Medicare intends to use 

PQRS and cost data from groups of EPs defined at the taxpayer 

identification number level to calculate the VM and then report the 

payment adjustments in the QRURs. As required in the act, CMS 

plans to apply the VM first to select physicians in 2015 and to all 

physicians in 2017.

 

13Starting in 2011 and continuing through 2015, eligible Medicare physicians who 

demonstrate meaningful use of certified EHR technology consistent with CMS 

requirements are eligible to receive Medicare EHR incentive payments. About 36 percent 

of EPs received incentive payments in 2012. See GAO, Electronic Health Record 

Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including 

Improved Quality of Care, GAO-14-207 (Washington, D.C.: Mar. 6, 2014).

14Registries qualified for reporting to CMS differ from clinical data registries—entities that

collect and analyze detailed information on the therapies that patients receive and 

changes in their clinical condition over time—in that their sole function is to compile and 

submit data to PQRS. See GAO, Clinical Data Registries: HHS Could Improve Medicare 

Quality and Efficiency through Key Requirements and Oversight, GAO-14-75

(Washington, D.C.: Dec. 16, 2013).

15Pub. L. No. 110-275, § 131(c), 122 Stat. 2494, 2526 (July 15, 2008).

16Pub. L. No. 111-148, §§ 3003(a), 3007, 124 Stat. 119, 367, 373 (Mar. 23, 2010).
 

Page 7 GAO-14-279 Medicare Provider Feedback

Figure 1: CMS’s Phased Approach to Providing Value Modifier (VM) Reports to Eligible Professionals (EP) 
 

Page 8 GAO-14-279 Medicare Provider Feedback

In our December 2012 report on physician payment incentives in the VM 

program, we found that CMS had yet to develop a method of reliably 

measuring the performance of physicians in small practices, that CMS 

planned to reward high performers and penalize poor performers using 

absolute performance benchmarks, and that CMS intended to annually 

adjust payments 1 year after the performance measurement period ends. 

We recommended that CMS develop a strategy to reliably measure the 

performance of small physician practices, develop benchmarks that 

reward physicians for improvement as well as for meeting absolute 

performance benchmarks, and make the VM adjustments more timely, to 

better reflect recent physician performance.17 CMS agreed with our 

recommendations, but noted that it was too early to fully implement these 

changes.

Private entities we reviewed provided feedback mostly to groups of 

primary care physicians practicing within newer delivery models. Each 

entity decided which measures to report and which performance 

benchmarks to use, leading to differences in report content across 

entities. Largely relying on claims data, health insurers spent from 4 to 

6 months to produce the annual reports. To meet the information needs of 

physicians, they all provided feedback throughout the year. The entities 

also generally offered additional report detail and other resources to help 

physicians improve their performance.

 

17GAO-13-160. 

Private Entities 

Selected a Range of 

Measures and 

Benchmarks to 

Assess Physician 

Group Performance, 

and Provided 

Feedback More than 

Once a Year
 

Page 9 GAO-14-279 Medicare Provider Feedback

The private entities in our review had discretion in determining the 

number and type of physicians to be included in their performance 

reporting initiatives, and their feedback programs generally included only 

physician groups participating in newer delivery models—medical homes 

and ACOs—with which they contract.18

Private entities’ feedback programs were generally directed toward 

primary care physician practices. One entity defined primary care as 

family medicine, internal medicine, geriatrics, and pediatrics; and included 

data on the services furnished by nurse practitioners and physician 

assistants in its medical group reports. The entities indicated that they 

rarely provided reports directly to specialty care physician groups. Among 

those that did, the programs typically focused on practice areas 

considered significant cost drivers—obstetrics/gynecology, cardiology, 

and orthopedics.

Within this set of providers, the 

entities used various approaches to further narrow the physician groups 

selected to receive performance feedback. For example, one entity told 

us that only physician groups accredited by a national organization 

focused on quality were eligible for participation in its medical home 

program, which included physician feedback reports.

Entities further limited their physician feedback programs to groups 

participating in medical homes with a sufficient number of attributed 

enrollees to ensure the reliability of the reported measures. In medical 

home models, enrollees are attributed to a physician (or physicians) 

responsible for their care, who is held accountable for the quality and cost 

of care, regardless of by whom or where the services are provided. 

Among those entities we spoke with, the minimum enrollment size for 

feedback reporting varied widely, with most requiring a minimum of 

between 200 and 1,000 attributed enrollees to participate in the program. 

For example, one entity had two levels of reporting in its medical home 

program, differentiated by the number of attributed enrollees. In one 

medical home model, the entity required more than 2,000 attributed 

enrollees for participation and rewarded the practices through shared 

 

18Some entities in our study had previous experience in giving feedback to providers in 

these delivery models, while other entities were in the process of transitioning their 

incentive programs from pay for performance programs to these newer delivery models. 

Most entities told us they disseminated performance reports to a designated point of 

contact for subsequent distribution to the group’s physicians. Many entities said they 

tracked report receipt or website downloads, and they stated that report use is high, 

especially when tied to incentive payments.

Private Entities Focused 

Their Feedback Efforts on 

Groups of Primary Care 

Physicians Practicing 

within Newer Delivery 

Models
 

Page 10 GAO-14-279 Medicare Provider Feedback

savings. In a second medical home model, the entity included practices 

with fewer than 1,000 attributed enrollees, but these practices did not 

share in any savings.

According to the entities in our study, small physician practices (including 

solo practitioners) typically received performance reports for quality 

improvement purposes only. Because smaller practices may not meet 

minimum enrollment requirements needed for valid measurement,19

private entities generally did not link their performance results to payment 

or use them for other purposes. For example, one entity provided 

feedback to practices of one to three primary care physicians upon 

request, but did not publicly report these practices’ data on its website. To 

increase the volume of patient data needed for reliable reporting, some 

entities pooled data from several small groups and solo practitioners and 

issued aggregate reports for those small practices. Most of the entities 

that used this method said they applied their discretion in forming these 

“virtual” provider groups; however, another entity commented that 

allowing small practices to voluntarily form such groups for measurement 

purposes would be advantageous.

Because each private entity in our study determined the number and 

types of measures on which it evaluated physician performance, the 

measures used in each feedback program differed. Each entity decided 

on quality measures to include, and many also identified utilization or cost 

measures for inclusion.20

 

19Practices with small numbers of attributed enrollees can receive skewed results that do 

not appropriately reflect the practice’s average performance over time. One entity told us 

that even one or two catastrophic cases in small patient populations could 

disproportionately affect the results and could be misleading.

In addition, one entity noted that it allowed 

ACOs to choose 8 to 10 measures from among a set of about 18 

measures. To assess physicians’ quality and utilization/cost results, the 

entities used absolute or relative performance benchmarks.

20Entities told us they generally used nationally endorsed quality measures, but have 

considered adding measures to meet the particular needs of their program and 

physicians. Nationally endorsed measures could include measures from the National 

Quality Forum or the National Committee for Quality Assurance’s Healthcare 

Effectiveness Data and Information Set. For example, at one entity, a multistakeholder 

Measurement and Reporting Committee supplemented the National Quality Forumendorsed measures with nonendorsed generic drug measures.

Private Entities Decided 

Which Measures to Report 

and Compared Physician 

Performance to Various 

Benchmarks, Leading to 

Differences in Report 

Content across Entities
 

Page 11 GAO-14-279 Medicare Provider Feedback

Private entities generally report on physician quality using many more 

process of care measures than outcomes of care measures.21 Entities in 

our review commonly included indicators of clinical care in areas such as 

diabetes care, cardiovascular health, and prevention or screening 

services for both their adult and pediatric patients. The most common 

measure reported by all entities was breast cancer screening, followed by 

hemoglobin A1C measures,22

We found wide variation in the number and type of measures in private 

entities’ quality measure sets.

a service used to monitor diabetes.

23 The total number of quality measures 

used in the feedback reports ranged from 14 to 51.24 Measures typically 

fell into one of several measurement areas, each with as few as one or as 

many as 20 individual measures. For example, in the quality 

measurement areas for pulmonary and respiratory conditions, one private 

entity reported on a single measure (appropriate use of medications for 

asthma), while another reported three measures (appropriate use of 

medications for asthma, appropriate testing for pharyngitis, and 

avoidance of antibiotic treatment for adults with acute bronchitis). 

Although primarily focused on clinical quality measures, entities also 

included nonclinical measures, such as patient safety and patient 

satisfaction. (See app. II for more information on the number and types of 

quality measures included in sample reports provided by the entities we 

reviewed.)

 

21Process measures include clinical activities such as tests, screenings, and 

immunizations. In contrast, outcomes measures require data about patient health, such as 

the percentage of a physician’s patients at target blood pressure.

22The hemoglobin A1C test is a blood test used to manage type 1 or type 2 diabetes by 

looking at the patient’s average blood sugar level for a period of time. A high hemoglobin 

A1C level indicates poor control of diabetes. 

23In a study of 23 health insurers accounting for 66 percent of U.S. commercial 

enrollment, America’s Health Insurance Plans found wide variation in measures under 

common measurement areas. See A. Higgins, G. Veselovskiy, and L. McKown, “Provider 

Performance Measures in Private and Public Programs: Achieving Meaningful Alignment 

With Flexibility to Innovate,” Health Affairs, vol. 32, no. 8 (2013).

24According to one entity, physicians complained that receiving feedback on as many as 

29 performance measures did not support meaningful patient care.

Quality Measures
 

Page 12 GAO-14-279 Medicare Provider Feedback

Even when entities appeared to report on similar types of measures in 

common areas, we found considerable variability in each measure’s 

definition and specification. For this reason, results shown in physician 

feedback reports may not be comparable across entities. As shown in 

figure 2, the diabetes hemoglobin A1C measure was defined and used in 

different ways in our selected entities’ reports. In some cases, entities 

calculated the percentage of enrollees with diabetes within a certain age 

range that received the test. In other cases, the entities calculated the 

percentage of enrollees with diabetes within a certain age range that had 

either good or poor control of the condition, as determined from a 

specified hemoglobin A1C result. In addition, some entities defined their 

diabetic patient population as enrollees from 18 to 75 years of age, while 

another did not indicate the age range, and one entity set the age range 

from 18 to 64 years of age.
 

Page 13 GAO-14-279 Medicare Provider Feedback

Figure 2: Private Entity Examples of Hemoglobin A1C Measures as Presented in Four Sample Reports
 

Page 14 GAO-14-279 Medicare Provider Feedback

Some, but not all, private entities in our review included utilization or cost 

measures in their performance reports to physicians. Total cost of care 

per enrollee was the most commonly used measure, but cost measures 

disaggregated by type of service—facility, pharmacy, primary care 

physician, and specialty—were also used. Some entities described how 

they limited their reporting of a total cost of care measure to those 

medical groups with a large number of enrollees. In one case the 

minimum enrollment size was 20,000 enrollees and in another it was 

2,500 enrollees. Officials from one entity also told us that they allowed 

smaller physician practices to combine their data in order to meet the 

required number of enrollees for receiving feedback on cost of care.

In addition to feedback on the total cost of care per enrollee, some reports 

given to groups of primary care physicians contained information on the 

cost of care provided by specialists in the entity’s network. For example, 

one entity provided trend data that included the number of specialist visits 

(total and by type) and the number of patients with one or more visits for 

these specialty areas. (See fig. 3.) For the two specialties with the most 

enrollee visits during the measurement period—orthopedic surgery and 

dermatology—the entity also provided the medical group with data on 

which specialists were seen most frequently and their cost per visit. This 

information was intended to encourage cost-efficient referrals. Another 

entity said it was focused on a program in July 2013 to provide feedback 

to primary care physicians on cardiologists’ performance showing where 

care was being delivered most efficiently. By providing such information, 

the entity expected primary care physicians to take cost differences into 

account when making referrals, rather than basing referrals solely on 

historical habits. Disseminating information to primary care physicians 

about the relative cost of specialty care providers is a key aspect of 

medical home and ACO programs.

Utilization or Cost Measures
 

Page 15 GAO-14-279 Medicare Provider Feedback

Figure 3: Private Entity’s Display of Information on Specialty Referral Patterns in a Sample Report

The entities were fairly consistent in the number and types of utilization 

measures they selected for feedback reporting. The most common 

utilization measures reported by our private entities were physicians’ 

generic drug prescribing rates, followed by emergency department visits, 

inpatient visits, hospital readmissions, and specialist visits. One entity 

provided additional detail under the emergency department visits 

measure to show the number of patients that repeatedly seek care at 

emergency departments. Officials from the entity told us that this measure 

was included to alert physicians of potentially avoidable hospital visits so 

that they can encourage patients to use office-based care before seeking 

care in more costly settings. (See examples of this measure as presented 

by private entities in their sample reports in fig. 4.)
 

Page 16 GAO-14-279 Medicare Provider Feedback

Figure 4: Private Entity Examples of Emergency Department (ED) Visit Measures as 

Presented in Two Sample Reports

Note: In example 2, Ambulatory Care Sensitive Conditions (ACSC) refers to conditions where 

appropriate ambulatory care prevents or reduces the need for admission to the hospital.

To evaluate physician performance, the selected private entities 

compared the measures data to different types of benchmarks. Some 

entities compared each physician group’s performance results to that of a 

peer group (e.g., others in the entity’s network or others in the 

collaborative’s state or region); some entities compared physician groups’ 

results to a pre-established target; and others gauged physician groups’ 

progress relative to their past performance. (See fig. 5.) Entities generally 

used two or three such benchmarks in their feedback reports. For 

example, one entity separately displayed results for the medical home’s 

commercially insured, Medicare insured, and composite patient 

population. Within each of these population groups, it compared the 

practice’s performance to the average for nonmedical home practices, as 

well as to the practice’s performance in the prior measurement year. The 

entity also gave narrative detail to indicate favorable or unfavorable 

performance. The most common benchmark for the entities in our study 

was a physician group’s performance relative to the previous 

measurement period. However, some entities used this benchmark only

for utilization/cost measures and not for quality measures.

Benchmarks
 

Page 17 GAO-14-279 Medicare Provider Feedback

Figure 5: Private Entity Examples of Benchmark Comparisons as Presented in 

Three Sample Reports

Note: In example 2, the state Achievable Benchmark of Care (ABC) refers to the health care 

collaborative’s calculated benchmark for the state’s clinics based on its own criteria.
 

Page 18 GAO-14-279 Medicare Provider Feedback

Private entity officials told us they relied on claims as their primary data 

source for performance reporting. However, several private entities noted 

shortcomings in relying solely on claims data—the billing codes that 

describe a patient’s diagnoses, procedures, and medications—for 

performance reporting.25 Some entities supplemented their claims data by 

obtaining information from EHRs, patient satisfaction surveys, or chart 

extractions.26

The health insurers in our review typically spent from 4 to 6 months to 

produce and distribute annual performance reports; in contrast, the health 

care collaboratives spent 9 to 10 months. (See illustrations of these 

timelines in fig. 6.) As is common in the health insurance industry, payers 

require a 3-month interval after the performance period ends—referred to 

as the claims run-out—to allow claims for the services furnished late in 

the measurement period to be submitted and adjudicated for the report. 

The claims run-out was followed by 1 to 3 months to prepare the data, a 

period that allowed for provider attribution, risk-adjustment,

Entities noted that using EHR data was resource-intensive 

for both providers and payers, because they depended on physician 

groups to submit the information. The entities we spoke to have had 

limited success in using EHR data as a primary data source, although 

many saw it as complementary to claims data. Another entity 

supplemented its claims data with data from registries that compile 

information from administrative data sets, patient medical records, and 

patient surveys, and thus have the capacity to track trends in quality over 

time.

27

 

25Some services a patient receives are not paid for by the entity (such as care furnished at 

a Department of Veterans Affairs facility) and therefore the entity’s claims data may give 

an incomplete picture of a patient’s health.

measure 

26Since claims are designed for reimbursement purposes, the data are likely to 

encompass all services and supplies furnished by a provider. However, because payment 

in an FFS setting is not directly related to the number or type of conditions for which the 

physician codes, an EHR may have a more complete set of patient diagnoses than claims 

data. In addition, EHRs contain clinical data—lab results or vital signs—that can be used 

to identify conditions that may not have been recognized or coded by the physician.

27Data on costs per enrollee are risk-adjusted to reflect the enrollee’s demographics and 

health status. This adjustment helps ensure that providers are not disadvantaged in the 

comparisons for serving patients with poor health status.

Largely Relying on Claims 

Data, Health Insurers 

Spent 4 to 6 Months to 

Produce Annual Reports 

and Typically Provided 

Feedback in the Interim
 

Page 19 GAO-14-279 Medicare Provider Feedback

calculation,28 and quality assurance.29

Figure 6: Illustration of Timelines to Report Production for Health Insurers and 

Statewide Health Care Collaboratives

One statewide health care 

collaborative stated that the quality assurance process is helpful in 

increasing physician trust because the group is able to compare its own 

data with the collaborative’s data before results are final. The statewide 

health care collaboratives we spoke with required additional time to 

collect and aggregate data from multiple health insurers, and their final 

reports were issued at least 9 months after the end of the performance 

period. The time needed for some or all of these report production steps 

varied depending on the entity and the types of measures included.

 

28To calculate the percentage of a defined patient population that receives a particular 

process of care or achieves a particular outcome, entities define a denominator population 

by demographic information or diagnosis. For example, to calculate the rate of dilated 

macular examinations, the denominator could be specified as all patients aged 50 years 

and older with a diagnosis of age-related macular degeneration.

29The quality assurance process may entail several steps in reviewing data for errors and 

accuracy, including data submission audits and internal quality checks. Some entities said 

that they included a physician group review period that allows groups to appeal their 

results using supporting data.
 

Page 20 GAO-14-279 Medicare Provider Feedback

Collaboratives often used all-payer claims databases—centralized data 

collection where each payer submits claims data on that state’s health 

care providers—for aggregate reporting to providers. Officials from 

entities told us that all-payer claims databases are helpful because they 

provide physicians with a better picture of their entire patient panel, not 

just results determined by individual payers for limited sets of patients. 

One entity noted that it aggregates its quality data with other payers in its 

commercial market through a statewide organization, and no one payer 

can provide statistically meaningful data to a physician group on its own. 

Officials from one entity with all-payer claims database experience told us 

that the addition of Medicare data into these databases would improve 

the information available for measurement and feedback. In addition, one 

entity suggested that a multipayer database could help with feedback to 

physicians in groups of all sizes, including small practices, because the 

higher number of patients would generate sufficient data for calculating 

reliable measures. However, one entity acknowledged that using all-payer 

databases requires more time for merging data from different payers in 

different formats, and another entity noted the challenges of customizing 

reports for each medical groups’ patient population.

Private entities told us that physicians valued frequent feedback on their 

performance so that they have time to make practice changes that may 

result in better performance by the end of the measurement period. In 

response, these entities typically provided feedback reports on an interim 

basis throughout the measurement period. Interim reports typically 

covered a 1-year performance period, and were commonly issued on a 

rolling monthly, quarterly, or semiannual schedule. Entities also noted that 

frequent reporting throughout the period updated physicians on their 

performance so that year-end results were better expected and 

understood. Some entities in our study elected to issue interim reports 

that build up to the 12-month performance period by continually adding 

data from month to month. Those that used preliminary data that may not 

account for all final claims in building reports told us that such data starts 

to become useful about 3 to 6 months into the performance year. They 

also stated that, although the interim reports may be limited by the use of 

rolling or incomplete data, providers generally seek this information for 

early identification of gaps in care.
 

Page 21 GAO-14-279 Medicare Provider Feedback

Private entities generally offered additional report detail intended to 

enhance physicians’ understanding of the information contained in their 

reports or in response to physician requests for more data. Private entity 

officials told us that, because physicians prefer dynamic reports with as 

much detail as possible, they generally sent reports that can be expanded 

to show individual physician or patient-level data. Some entities formatted 

their reports to include summary-level information on quality and cost 

measures in labeled sections, with supplemental information following the 

summary data. Other entities provided additional reports or supplemental 

data through a web portal that allowed providers to see individual 

physician or patient-level detail. Private entities sent reports in multiple file 

formats, such as in a spreadsheet, some of which allowed report 

recipients to sort their data.30

Entities in our study also offered resources designed to assist physician 

groups with actionable steps they can take to improve in the next 

performance period. Most entities told us they offered resources to 

physician groups, such as consultations with quality improvement 

professionals, forums for information-sharing, and documents on best 

practices. For example, one entity’s staff worked directly with practices to 

improve their results by distributing improvement guidelines for each 

performance measure included in the feedback report. In addition, the 

entity’s officials told us they also convened workgroups to review trend 

information and paid particular attention to differences between medical 

homes and nonmedical homes.

 

30In response to provider needs, entities were flexible in how they distributed reports. 

Entities told us they primarily distributed reports over secure email or through a web 

portal. One entity sent copies by mail to reach small, rural providers.

Private Entities Generally 

Offered Access to 

Additional Report Detail 

and Other Resources to 

Help Physicians Improve 

Performance
 

Page 22 GAO-14-279 Medicare Provider Feedback

CMS has provided feedback to increasing numbers of physician practices 

each year in order to eventually reach all physicians. Each medical 

group’s chosen method of quality data submission determined the quality 

measures included in its report, to which CMS added health care costs 

and certain outcomes measures. CMS’s report generation process took 

slightly longer than that of most private entities in our study, and the 

agency did not provide interim performance data during the measurement 

period. CMS feedback reports have included information to assist 

providers in interpreting their performance results.

Unlike the private entities we contacted, which selected a limited set of 

physicians to receive feedback reports, CMS is mandated to apply the 

VM to all physicians by 2017. Therefore, the agency faces certain 

challenges not faced by private entities as it has expanded its feedback 

program to reach increasing numbers of physicians. In preparation for 

implementation of the VM, CMS provided performance reports to nearly 

4,000 medical groups in September 2013. In 2014, CMS plans to 

disseminate reports to physicians in practices of all sizes.

As of September 2013, CMS had not yet determined how to report to 

smaller groups and physicians in solo practices. According to CMS, the 

decision not to present VM information to smaller groups stemmed from 

concerns regarding untested cost metrics and administrative complexity. 

CMS agreed with a 2012 GAO recommendation to develop a strategy to 

reliably measure the performance of solo and small physician practices, 

but has not yet finalized such a strategy.31

 

31See GAO-13-160. 

CMS Feedback 

Included GroupDetermined Physician 

Quality Measures and 

Only One 

Benchmark; CMS 

Issued Reports Less 

Frequently than 

Private Entities

CMS Provided Feedback 

to Physicians in Groups 

with 25 or More Eligible 

Professionals in 2013
 

Page 23 GAO-14-279 Medicare Provider Feedback

Under the CMS approach to performance reporting, the content of 

feedback reports related to quality measures may vary across providers. 

Unlike our selected private entities, the agency has allowed physician 

groups to select the method by which they will submit quality-of-care data, 

which, in turn, determines the measures on which they receive feedback. 

CMS used claims data for a consistent set of measures in all of its 

feedback reports for performance on cost and outcomes.

For the CMS 2013 reports, medical groups submitted data on quality 

measures to CMS via a web interface or through a qualified registry; if a 

group did not select either of these options, the agency calculated quality 

measures based on claims data. Both CMS and private entities focused 

on preventive care and management of specific diseases.32

• Web interface. Quality measures under this method pertain to care 

coordination, disease management, and preventive services.33 CMS 

required groups reporting via the web interface to submit data on 17 

quality measures—such as hemoglobin A1C levels for control of 

diabetes—for a patient sample of at least 218 beneficiaries.34

• Registries. Some groups submitted data for quality measures via 

qualified registries—independent organizations, typically serving a 

particular medical specialty, that collect and report these data to CMS. 

CMS required groups reporting to a qualified registry to submit at least 

 

32Although specific measures vary by reporting method, CMS places all quality measures 

within an agencywide national quality strategy. In 2011, HHS issued a National Quality 

Strategy establishing six broad priority domains: patient and family engagement, patient 

safety, care coordination, population/public health, efficient use of health care resources, 

and clinical process/effectiveness. Experts have recommended that CMS align measures 

among its various Medicare payment incentive programs, such as PQRS and the EHR 

Incentive Programs, and CMS has begun to do so. See C. Damberg, Physician Payment 

Reform: Designing a Performance-Based Incentive Program. Testimony before the House 

Energy and Commerce Committee, Subcommittee on Health, on June 5, 2013.

33CMS’s disease management measures relate to coronary artery disease, diabetes, 

heart failure, hypertension, and ischemic vascular disease; and the preventive care 

measures include screenings for breast cancer, colorectal cancer, body mass index, 

tobacco use, high blood pressure, and clinical depression; and influenza and 

pneumococcal vaccinations.

34If the pool of eligible assigned beneficiaries is less than 218, then providers must report

on all assigned beneficiaries.

CMS Feedback Contained 

Varying Quality but 

Consistent Cost and 

Outcomes Measures and 

Assessed Performance 

Against a Single 

Benchmark

Quality Measures
 

Page 24 GAO-14-279 Medicare Provider Feedback

three measures—such as whether cardiac rehabilitation patients were 

referred to a prevention program—for at least 80 percent of patients.35

• Administrative claims. As a default, if a group did not report via web 

interface or qualified registry, CMS calculated quality measures using 

claims data. In September 2013, the majority of groups with 25 or 

more EPs—nearly 90 percent—received quality scores based on 

claims data. CMS calculated performance on a set of 17 quality 

indicators, including several composite measures. For example, the 

diabetes composite measure included several different measures of 

diabetes control.

Regardless of the method a group selected to submit quality-of-care data, 

CMS used claims to calculate three outcomes measures—two 

ambulatory care composite measures and hospital readmission. One 

ambulatory care composite included hospitalization rates for three acute 

conditions: bacterial pneumonia, urinary tract infections, and dehydration. 

Another composite included hospitalization rates for three chronic 

conditions: diabetes, chronic obstructive pulmonary disease (COPD), and 

heart failure.

CMS included cost measures—several of which differed from the 

measures private entities in our study reported to physicians—in all 2013 

feedback reports (see fig. 7). Using claims data, CMS calculated an 

overall measure of the cost of care as the total per capita costs for all 

beneficiaries attributed to each physician group.36

 

35Depending on the specialty focus, qualified registries may collect and submit data from 

over 200 CMS-determined measures.

In addition, CMS 

separately reported total per capita costs for attributed beneficiaries with 

any of four chronic conditions: diabetes, heart failure, COPD, or coronary 

artery disease. This contrasts with the private entities that typically 

measured a more limited set of measures focused on physicians’ generic 

drug prescribing rates and hospital utilization.

36Total per capita costs include services covered under Medicare Part A and services 

covered under Medicare Part B furnished by all providers seen by the beneficiary.

Cost Measures
 

Page 25 GAO-14-279 Medicare Provider Feedback

Figure 7: Cost Measures Displayed in CMS’s 2013 Quality and Resource Use Reports

Note: Each domain score is an average of the standardized scores for all measures in the domain 

with at least 20 cases. Up to six equally weighted quality domain scores make up a medical group 

practice’s quality composite score.

While private entities typically displayed performance information relative 

to multiple benchmarks for certain quality measures—such as peer 

groups, pre-established targets, or past performance—CMS compared 

each physician group’s performance only to the national average (see 

fig. 8). National average rates comprised all EPs and provider groups that 

reported on that particular quality measure. For quality measures, the 

agency compared a group’s current performance to the prior-year 

national average of all groups. CMS reported calculating benchmarks by 

weighting the performance rate of each physician and group of physicians 

submitting data through any reporting mechanism for that specific quality 

measure, regardless of specialty, by the number of beneficiaries used to 

calculate the performance rate. According to CMS, where data for a 

measure are only available through one reporting option, such as a 

registry, the benchmark is the performance of all other groups that used 

the same reporting method to submit data for that quality measure. For 

cost measures, CMS compared a group’s current performance to currentyear national averages.37

 

37For cost measures, the peer group for medical groups of 100 or more EPs is all groups 

of 100 or more EPs, while the peer group for groups of 25 to 99 EPs is all groups of 25 or 

more EPs. CMS compares cost measures after risk-adjustment and price standardization.

Benchmarks
 

Page 26 GAO-14-279 Medicare Provider Feedback

Figure 8: Performance Benchmarks Displayed in CMS’s 2013 Quality and Resource Use Reports

According to CMS, this benchmarking approach should spur cost and 

quality improvement nationwide. However, this method may not always 

produce a national or nationally representative benchmark for quality of 

care, as it only captures providers who reported that measure in that year. 

In addition, a private entity in our review noted that national benchmarks 

do not reflect more local patterns of care. Several entities calculate 

benchmarks at the state or regional level; the performance of peers in the 

same geographic area may differ from national averages and have more 

relevance to the providers. For example, absent multiple performance 

benchmarks—both national and local—a physician group might be 

unaware that while its performance exceeds national benchmarks, it is 

below the average within the state. Moreover, as we concluded in a 2012 

report,38

CMS also provided broader benchmarks, in the form of composite scores. 

CMS’s 2013 feedback reports also included a ‘‘first look’’ at the VM, which 

did not yet affect the physician group’s payment, but showed each group 

how its payments could be affected with the implementation of the VM in 

2017.

without consistent measures showing performance over time, a 

physician group cannot gauge whether its performance was improving.

39

 

38See 

The agency determined the VM based on each group’s 

performance on quality and cost measures relative to other Medicare 

GAO-13-160. 

39The 2015 VM, which will impact FFS payment in 2015 for groups with 100 or more EPs 

is to be based on the groups’ performance in 2013.
 

Page 27 GAO-14-279 Medicare Provider Feedback

providers. To determine the VM, CMS classified each quality measure 

into one of six domains, following the national priorities related to clinical 

care, patient experience, population/community health, patient safety, 

care coordination, and efficiency established in its National Quality 

Strategy. CMS then calculated a quality composite score, weighing each 

domain equally. Similarly, to produce a cost composite score, CMS 

aggregated the per capita costs for beneficiaries with four chronic 

diseases into one composite, and weighted this composite equally with 

total overall costs to produce a cost composite. CMS then combined the 

quality and cost composite scores and compared them to national 

averages to determine an overall quality tier,40 which then determined the 

group’s VM.41

 

40CMS determines whether a group’s performance was significantly different from average

performance, with a 95 percent confidence interval or one standard deviation above or 

below the mean.

(See fig. 9.)

41Although the feedback report is based on claims from all EPs in the medical group, only 

payments for physician services are affected by the VM.
 

Page 28 GAO-14-279 Medicare Provider Feedback

Figure 9: CMS Sample Composite Scores, Quality Tier, and Value Modifier

Also, unlike the private entities we interviewed, CMS’s feedback reports 

did not provide information on a group’s performance relative to prior 

years. CMS plans to expand to multiple benchmarks in the future—for 

example, CMS finalized for 2014 adjusting the benchmark based on the 
 

Page 29 GAO-14-279 Medicare Provider Feedback

specialty composition of the groups. In 2012, GAO recommended that 

CMS develop benchmarks that assess the degree of performance 

improvement as well as the extent to which performance meets absolute 

targets.42 However, according to CMS, it is premature to establish such 

benchmarks without more data from medical groups, increased 

participation in PQRS, and an understanding by providers that the 

reported data will be used to adjust payment.

CMS’s report generation process took longer than that of most private 

entities in our study because it required more steps. While most health 

insurers generated performance reports in 4 to 6 months, CMS issued 

reports about 9 months after the end of the January to December 2012 

reporting period.

To produce its 2013 physician feedback reports using administrative 

claims, CMS began with the standard claims run-out period followed by 

intervals for provider attribution, measure calculation, risk-adjustment, 

and quality assurance. (See fig. 10.) CMS officials said they allowed a 

3-month run-out interval to account for providers’ late-year claims 

submissions. After the run-out period, CMS required 5 to 6 months for a 

series of additional tasks needed to prepare the data for reporting. For 

groups that submitted data to CMS via the web interface or registry 

options, CMS gave these groups 3 months to submit such data after the 

end of the 12-month performance period. CMS then calculated the 

measures for these options over a period of the next several months. 

Although FFS beneficiaries see multiple physicians, CMS attributed each 

beneficiary to a single medical group through its yearly attribution 

process.43 It used the claims for the 12-month reporting period to 

determine which groups provided the beneficiary the most primary care 

and then assigned responsibility for performance on quality and cost 

measures to that group. Following attribution, the agency risk-adjusted 

the cost measures to account for differences in beneficiary 

characteristics44

 

42See 

and complexity, and standardized the cost measures by 

GAO-13-160. 

43Private entities providing reports in a collaborative care setting such as a medical home 

do not have to complete this step, as each beneficiary has already been associated with a 

provider.

44Patient characteristics include age, gender, Medicaid eligibility, history of medical 

conditions, and end-stage renal disease.

CMS Spent 9 Months to 

Produce the 2013 

Feedback Reports, and 

Did Not Provide Interim 

Reports
 

Page 30 GAO-14-279 Medicare Provider Feedback

removing all geographic payment adjustments. Finally, CMS officials said 

they performed data checks to ensure accuracy before the reports were 

disseminated.

Figure 10: Report Generation Timeline for CMS Performance Feedback Reports, September 2013

According to health insurers and collaboratives, physicians find that 

frequent feedback enables them to improve their performance more 

quickly;45 however, CMS did not provide physicians interim performance 

feedback.46

 

45In addition to evidence from our selected entities, recent research on private feedback 

reporting found that timeliness of data is critical for management of patient care, as well as 

for tracking performance and monitoring progress toward improvement goals. For 

example, based on a review of literature on private reports, an examination of selected 

examples of community quality collaborative feedback reports, and a case study of 

Cincinnati’s experience with private reporting, one study recommended that private 

feedback reports should be updated at least quarterly. See Dale Shaller and David 

Kanouse, Private “Performance Feedback” Reporting for Physicians: Guidance for 

Community Quality Collaboratives, Publication No. 13-0004 (Rockville, MD: Agency for 

Healthcare Research and Quality, Nov. 2012).

However, with only annual feedback from CMS, physicians 

may be missing an opportunity to improve their performance on a more 

frequent basis. Asked if more frequent reporting was considered, CMS 

officials cited concerns about the time it would take to generate each set 

of reports. With each round, the agency would need to attribute all 

beneficiaries to a medical group, risk-adjust and standardize the cost 

measures, and compute the benchmarks for each measure. In addition, 

providing interim reports on quality data would require certain providers to 

report more frequently. For example, providers who submit via registry 

would need to finalize their data more often than annually. However, 

experts and CMS officials have stated that, with continued adoption of 

46Providers can access quarterly reports from CMS based on claims data. However, these 

interim reports only show the number of measures (or measures groups) reported, and the 

number of those accurately reported. They do not show performance rates.
 

Page 31 GAO-14-279 Medicare Provider Feedback

advanced data reporting technology, CMS may be able to generate 

reports more frequently.

CMS provided general information on its website and through the 

Medicare Learning Network, to assist providers in understanding the 

performance feedback and VM.

47

A representative acting on behalf of a medical group could access the 

group’s QRUR. In addition, CMS’s web-based reports allowed providers 

to access further detail on the Medicare beneficiaries attributed to the 

group. For example, physicians could view their patients’ percentage of 

total cost by type of service and hospital admission data.

Unlike private entities, CMS has not 

provided tailored guidance or action steps to help providers improve their 

scores. However, CMS resources included steps to access reports, a 

review of methodology, suggested ways to use the data in reports, and 

contact information for technical support.

CMS included explanatory information within the reports for providers. In 

addition to comparative performance data, reports made available in 

September 2013 included a description of the attribution methods, the 

number of providers billing in each medical group, information about each 

attributed patient’s hospitalizations during the year, and other details 

about the group’s performance. In addition, CMS included within the 

QRUR a glossary of terms used in the feedback report.

Payers have been refining their performance reports for physicians, a key

component of their VBP initiatives. Private entities have selectively rolled 

out their feedback programs, generally applying them to relatively large 

groups of primary care physicians participating in medical homes and 

ACOs. Although they are not uniform in their approaches, the entities in 

our study used their discretion to select a limited number of quality and 

utilization/cost measures, calculated them using claims data, and used 

them to assess performance against a variety of benchmarks. In 

response to physicians’ needs, their feedback reports tended to be 

frequent, timely, and dynamic.

 

47CMS runs the Medicare Learning Network as an outreach program to educate health 

care professionals on CMS programs, using e-mail, calls, web-based courses, and other 

methods.

CMS Included Explanatory 

Information in Its Reports 

and Offered Other 

Resources Online

Conclusions
 

Page 32 GAO-14-279 Medicare Provider Feedback

CMS’s approach to performance reporting faces some unique challenges. 

First, it is driven by the statutory requirement that, by 2017, Medicare pay 

FFS physicians in groups of all sizes, including specialists, using a VM. 

Second, the agency has had to develop the feedback program in the 

context of pre-existing incentive programs, such as PQRS. CMS finalized 

several key changes to the feedback program for future reporting periods, 

as it expands the application of the VM to all physicians. Specifically, 

CMS continues to modify program components such as measures and 

reporting mechanisms as it works to align the reporting and feedback 

aspects of multiple programs. Despite these program modifications, we 

found that certain features of private entities’ feedback programs, which 

are lacking in CMS’s program, could enhance the usefulness of the 

reports in improving the value of physician care.

• CMS’s use of a single nationwide benchmark to compare 

performance on quality and cost ignores richer benchmarking 

feedback that could benefit physicians. Private entities in our study 

measured provider performance against several benchmarks. CMS’s 

reliance on a national average as the sole benchmark precludes 

providers from gauging their performance relative to their peers in the 

same geographic area. Without such contextual information, providers 

lack the feedback to better manage their performance and target 

improvement efforts.

• Additionally, CMS disseminates feedback reports only once a year 

(for example, September 2013). This gives physicians little time 

(October through December) to analyze the information and make 

changes in their practices to score better in the next measurement 

period. The private entities we reviewed sent reports more than once 

a year, and reported that greater frequency of reporting enabled more 

frequent improvements. Without interim performance reports, 

providers may not be able to make needed changes to their 

performance in advance of their annual VM payment modifications.

Our findings also support past GAO recommendations that CMS reward 

physicians for improvement as well as performance against absolute 

benchmarks, and develop a strategy to reliably measure solo and small 

practices, such as by aggregating data.

As CMS implements and refines its physician feedback and VM 

programs, the Administrator of CMS should consider taking the following 

two actions to help ensure physicians can best use the feedback to 

improve their performance:

Recommendations for 

Executive Action
 

Page 33 GAO-14-279 Medicare Provider Feedback

• Develop performance benchmarks that compare physicians’ 

performance against additional benchmarks such as state or regional 

averages; and

• Disseminate performance reports more frequently than the current

annual distribution—for example, semiannually.

We provided a draft of this report to HHS for comment. In its written 

response, reproduced in appendix III, the department generally agreed 

with our recommendations, and reiterated our observation that the 

agency faces unique challenges with its mandate to report to Medicare 

FFS providers in groups of all sizes that encompass all specialty care 

areas.

HHS conditionally agreed with our recommendation that reporting 

physician performance using multiple benchmarks would be beneficial, 

but asked for further information on private entities’ practices and their 

potential use for Medicare providers. As we stated in the report, private 

entities generally use two or three different types of benchmarks to 

provide a variety of performance assessments. We found alternative 

benchmarks that could enhance Medicare feedback reporting by allowing 

physicians to track their performance in their own historical and 

geographic context. For example, some entities’ reports included 

physician group performance on certain measures relative to their past 

performance, a recommendation we previously made to HHS in

December 2012. Although it agreed to consider developing benchmarks 

for performance improvement, HHS has yet to do so. A comparison to 

past performance allows a medical group to see how much, if at all, it has 

improved regardless of where it stands relative to its peers. In this way, 

CMS can motivate physicians to continuously improve their performance. 

In addition, some entities in our review compared physician performance 

data to statewide or regional-level benchmarks. Because of the number of 

Medicare physicians, CMS has extensive performance data, which could 

enable more robust localized peer benchmarks than any individual health 

plan could generate. As we noted, such benchmarks reflect more local 

patterns of care that may be more relevant to physicians than 

comparisons to national averages alone.

HHS further asserted that, because the physician feedback program’s key 

purpose is to support the national VM program, it is appropriate to limit 

reporting to a single national benchmark. HHS expressed concern that 

displaying other benchmarks could be misleading and confusing for the 

Agency Comments 

and Our Evaluation
 

Page 34 GAO-14-279 Medicare Provider Feedback

purposes of the VM. However, CMS’s reports provide a group’s VM 

payment adjustment in a concise, one-page summary, as shown in 

figure 9. We do not believe that additional benchmark data, displayed 

separately, would detract from the information provided on the summary 

page, and could enhance the value of the reports for physicians.

HHS agreed with our second recommendation to disseminate feedback 

reports more frequently than on an annual basis. As seen in the private 

entity practices of using rolling or preliminary data for interim reporting, 

disseminating reports more frequently can assist physicians in making 

improvements to their performance before CMS determines their VM 

payment adjustment. HHS commented that producing more frequent 

reports would first require modifying the PQRS data collection schedules.

For example, groups of EPs that use the web interface and registry 

options currently are only required to submit data to CMS once a year. 

The registry option will eventually require groups to submit data to CMS 

on a quarterly or semiannual basis, and HHS noted that these 

requirements would have to be synchronized with the timing of data 

submission through the web interface and EHR options. 

The agency also provided technical comments, which we incorporated as 

appropriate.

We are sending copies of this report to the appropriate congressional 

committees and the Administrator of CMS. The report also is available at 

no charge on GAO’s website at http://www.gao.gov. If you or your staffs 

have any questions regarding this report, please contact me at (202) 512-

7114 or cosgrovej@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made major contributions to this report are 

listed in appendix IV. 

James Cosgrove

Director, Health Care
Appendix I: Private Entity and Medicare 

Performance Feedback for Hospitals

Page 35 GAO-14-279 Medicare Provider Feedback

This appendix contains information on the similarities and differences 

between private entities’ and Medicare’s performance reporting to 

hospitals. The private entities in our study provided feedback through a 

variety of value-based payment (VBP) initiatives and several entities have 

made accountable care organizations the focus of their feedback 

programs. Payers’ efforts to provide feedback to hospitals on their 

performance are centered on rewarding higher-quality and lower-cost 

providers of care.

We followed the same methodology for comparing how private entities 

and the Centers for Medicare & Medicaid Services (CMS) conduct 

performance feedback reporting for hospitals as we did for examining 

physician-focused feedback programs. We interviewed representatives of 

the nine selected private entities about their feedback reporting to 

hospitals, if any, with regard to report recipients, data sources used, types 

of performance measures and benchmarks, frequency of reporting, and 

efforts to enhance the utility of performance reports. One statewide health 

care collaborative in our review was established through a partnership 

between the state medical society and hospital association, and only 

provides feedback reports to hospitals. We similarly requested sample 

feedback reports for hospitals. We interviewed CMS officials and obtained 

CMS documentation on its hospital feedback reporting activities, and 

compared these to private entity efforts. We also reviewed a sample CMS 

hospital feedback report from July 2013.

CMS’s hospital VBP efforts over the past decade have evolved to provide 

performance feedback to a range of hospital types, with a focus on acute 

care hospitals. In 2003 the agency began with a quality incentive 

demonstration program designed to see whether financial incentives to 

hospitals were effective at improving the quality of inpatient care, and to 

publicly report that information. Since then, a number of laws have 

required CMS to conduct both feedback reporting and VBP programs for 

hospitals. These included the following:

• The Medicare Prescription Drug, Improvement, and Modernization Act 

of 2003, which required the establishment of the Hospital Inpatient 

Quality Reporting Program, a pay-for-reporting initiative.1

 

1

Pub. L. No. 108-173, § 501(b), 117 Stat. 2066, 2289 (Dec. 8, 2003).

The act also 

required CMS to make downward payment adjustments to hospitals 

Appendix I: Private Entity and Medicare 

Performance Feedback for Hospitals
Appendix I: Private Entity and Medicare 

Performance Feedback for Hospitals

Page 36 GAO-14-279 Medicare Provider Feedback

that did not successfully report certain quality measures. That 

downward payment adjustment percentage was increased by the 

Deficit Reduction Act of 2005.2

• The Patient Protection and Affordable Care Act established 

Medicare’s Hospital VBP Program for inpatient care provided in acute 

care hospitals.3

In reviewing current feedback reporting practices, we found that private 

entities and CMS report to hospitals on similar performance measures 

and that entities’ feedback generally contains publicly available data. 

Table 1 compares features of the hospital feedback produced by those 

private entities in our study that report to hospitals through a VBP 

initiative and CMS’s hospital VBP program.

Under this program, CMS withholds a percentage of 

all eligible hospitals’ payments and distributes those funds to highperforming hospitals.

 

2

Pub. L. No. 109-171, § 5001(a), 120 Stat. 4, 28 (Feb. 8, 2006).

3

Pub. L. No. 111-148, § 3001(a)(1), 124 Stat. 119, 353 (Mar. 23, 2010). Other hospital 

types, such as long-term care hospitals, are included under separate VBP programs.
Appendix I: Private Entity and Medicare 

Performance Feedback for Hospitals

Page 37 GAO-14-279 Medicare Provider Feedback

Table 1: Key Features of Hospital Feedback Reporting by Selected Private Entities and CMS

Report recipients

Private entities in our study reported to a range of hospital types CMS reported to hospitals covered under statute

• Private entities reported to acute care general hospitals, including 

critical access hospitals (CAH)a

• One entity limited the data reported to small hospitals, such as 

CAHs, because of their small volume and limited services, and 

another entity used 5 years of combined data in its annual report 

to increase data reliability for CAHs

• CMS provided reports to more than 3,000 acute care 

general hospitals nationwide

• CMS did not report to hospitals excluded from its 

statutory mandate, including those excepted from CMS’s 

Hospital Inpatient Quality Reporting (IQR) Program,b as 

well as those that do not meet minimum volume 

requirementsc

Data sources

Private entities compiled information from Medicare, states, and 

other sources

CMS used claims, patient survey, medical record, and 

other administrative data

• Private entities generally used publicly available Medicare, state

hospital association, and other data to report on performance

• Medicare data sources included CMS’s Hospital Compare 

website,d as well as CMS’s patient satisfaction surveys

• Some entities used other national data sources such as a quality 

indicator tool set from the Agency for Healthcare Research and 

Quality or national registries

• One entity used hospital-reported all-payer data, and another 

entity used voluntary hospital-reported data on infections

• CMS used data collected through its Hospital IQR 

Program, which included claims and administrative data, 

its patient satisfaction surveys, and other data

Measures

Private entities reported similar quality measures on processes of 

care, outcomes, patient safety, and patient satisfaction

CMS reported quality measures on clinical processes of 

care and patient satisfaction

• Private entities generally used similar measures on quality and 

utilization for hospital reporting, including patient safety and 

patient satisfaction

• Entities used as few as 15 and as many as 49 total measures in 

the four sample reports we obtained

• No entities reported to hospitals on cost measures

• One entity stated it focused on readmissions and emergency 

department care because reductions in these areas gave the 

entity a greater ability to control costs

• CMS will use three weighted quality domains in fiscal 

year 2014, covering clinical process (45% weighted), 

patient satisfaction (30% weighted), and outcomes 

(25% weighted) measures

• CMS included 13 clinical process measures, 8 patient 

satisfaction measures, and 3 outcomes measures 

(acute myocardial infarction, heart failure, and 

pneumonia 30-day mortality rates)

• CMS removed measures through annual rulemaking that 

outlines specific criteria, such as measures that have 

“topped-out”—where there is not a significant difference 

among all hospitals
Appendix I: Private Entity and Medicare 

Performance Feedback for Hospitals

Page 38 GAO-14-279 Medicare Provider Feedback

Benchmarks

Private entities generally compared hospital indicators to 

network, state, and national averages

CMS compared hospitals to achievement against all 

hospitals’ rates and to improvement over time

• Private entities generally compared hospital performance against 

absolute or relative benchmarks at the state and national levels

• One entity compared hospitals against network, regional, and 

national levels, as well as against previous measurement period 

performance

• CMS used both an achievement benchmark (a hospital’s 

performance against all other hospitals) and an 

improvement benchmark (a hospital’s performance from 

the baseline period to the performance period)

• CMS rewarded the higher of the two benchmark scores 

and aggregated these scores for each quality domain

Timeliness and frequency

Private entities generally reported to hospitals on an annual 

basis, with some interim reporting

CMS generally reported annual data on a quarterly basis

• Private entities generally reported to hospitals annually based 

on a 9-month or 12-month performance period

• Some private entities provided hospitals with interim feedback 

reports

• CMS provided annual reports to hospitals

• CMS’s reporting period varied by measure to ensure 

sufficient reliability

• CMS used a performance period of 9 months for valuebased payment (VBP) in fiscal year 2013 and plans to 

use a 12-month performance period beginning in 2014

Enhancing utility

Private entities offered resources to assist hospitals in acting on 

performance data

CMS has offered educational resources on its website 

and through national provider calls

• Some private entities offered consultations with quality 

improvement professionals, forums for information-sharing, and 

mentoring opportunities with hospital peers

• One entity hosted an annual best practices forum in 2012 where 

more than 400 hospitals shared their quality improvement 

experiences

• CMS posted information on its hospital reporting and 

VBP programs on its website

• CMS held national provider calls to solicit hospitals’ 

feedback

Source: GAO analysis of information from CMS and private entities.

Note: We did not independently verify the information we obtained in our interviews with private 

entities.

a

The Balanced Budget Act of 1997 established the CAH designation to target small rural hospitals 

with low patient volumes and short patient stays. A number of criteria are used to apply the CAH 

designation, including an average annual length of stay of 96 hours or less per patient for acute care 

services. Pub. L. No. 105-33, § 4201(c), 111 Stat. 251, 373-374 (1997).

b

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 required the 

establishment of the Hospital IQR Program, a pay-for-reporting initiative. Pub. L. No. 108-173, 

§ 501(b), 117 Stat. 2066, 2289 (2003).

c

Certain hospitals are excluded from participating in CMS’s hospital VBP program. These include 

hospitals that pose immediate jeopardy to the health or safety of patients; hospitals that do not meet 

the minimum requirements for cases, measures, or surveys during the measurement period; and 

hospitals that are exempted by the Secretary of Health and Human Services (for example, Maryland 

was exempt in fiscal year 2013 by submitting a report to the Secretary describing how its similar state 

program achieves or surpasses CMS’s hospital VBP program).

d

Medicare’s Hospital Compare website was started in 2005 through its Hospital Quality Initiative in 

collaboration with other stakeholders, such as the American Hospital Association and the National 

Quality Forum. On Hospital Compare, consumers can review quality-of-care data for over 4,000 

hospitals nationwide.
Appendix II: Quality Measures Used in Sample 

Physician Feedback Reports Provided by 

Selected Private Entities

Page 39 GAO-14-279 Medicare Provider Feedback

Table 2 summarizes the number of quality measures included in sample 

physician feedback reports we received from private entities in our study. 

These entities used their discretion to determine which measures to 

include in their reports. We analyzed the measures focused on quality of 

care and categorized them into common areas.

Table 2: Number of Quality Measures Categorized by Type Found in Sample Physician Feedback Reports Provided by 

Selected Private Entities

Entity A Entity B Entity C Entity D Entity E Entity F Entity G Entity H

Clinical areas reported

Cardiovascular 1 2 7 1 3 1 5 2 

Diabetes 4 3 8 4 9 4 3 4 

Medication management 0 0 6 0 0 2 5 0 

Mental health 2 0 0 0 0 4 0 0 

Musculoskeletal conditions 1 1 1 2 1 3 0 1 

Pediatric care 4 0 3 5 4 11 10 17

Prevention and screening 3 5 3 3 4 7 3 3 

Pulmonary and respiratory conditions 3 0 1 2 2 5 3 2 

Nonclinical areas reported

Patient safety 0 0 3 0 0 0 0 0 

Patient satisfaction 0 3 0 0 8 0 0 0 

Othera 0 0 0 4 20 0 7 0 

Total number of quality measures 18 14 32 21 51 37 36 29

Source: GAO analysis of private entity information

Note: For this analysis, we examined the measures included in sample physician performance 

feedback reports obtained from private entities. We categorized measures into common areas based 

on predominant patterns. One of the nine entities included in our review only provided feedback 

reports to hospitals, and is not shown here.

a

This area included measures related to information technology, access to care, participation in 

quality improvement initiatives or external recognition programs, and assessment and care plans for 

urinary incontinence.

Appendix II: Quality Measures Used in 

Sample Physician Feedback Reports 

Provided by Selected Private Entities
Appendix III: Comments from the Department 

of Health and Human Services

Page 40 GAO-14-279 Medicare Provider Feedback

Appendix III: Comments from the 

Department of Health and Human Services
Appendix III: Comments from the Department 

of Health and Human Services

Page 41 GAO-14-279 Medicare Provider Feedback
Appendix III: Comments from the Department 

of Health and Human Services

Page 42 GAO-14-279 Medicare Provider Feedback
Appendix III: Comments from the Department 

of Health and Human Services

Page 43 GAO-14-279 Medicare Provider Feedback
Appendix IV: GAO Contact and Staff 

Acknowledgments

Page 44 GAO-14-279 Medicare Provider Feedback

James Cosgrove, (202) 512-7114 or cosgrovej@gao.gov

In addition to the contact named above, individuals making key 

contributions to this report include Rosamond Katz, Assistant Director; 

Sandra George; Katherine Perry; and E. Jane Whipple.

Appendix IV: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments
Related GAO Products

Page 45 GAO-14-279 Medicare Provider Feedback

Electronic Health Record Programs: Participation Has Increased, but 

Action Needed to Achieve Goals, Including Improved Quality of Care. 

GAO-14-207. Washington, D.C.: March 6, 2014.

Clinical Data Registries: HHS Could Improve Medicare Quality and 

Efficiency through Key Requirements and Oversight. GAO-14-75. 

Washington, D.C.: December 16, 2013.

Medicare Physician Payment: Private-Sector Initiatives Can Help Inform 

CMS Quality and Efficiency Incentive Efforts. GAO-13-160. Washington, 

D.C.: December 26, 2012.

Medicare Program Integrity: Greater Prepayment Control Efforts Could 

Increase Savings and Better Ensure Proper Payment. GAO-13-102. 

Washington, D.C.: November 13, 2012.

Medicare Physician Feedback Program: CMS Faces Challenges with 

Methodology and Distribution of Physician Reports. GAO-11-720. 

Washington, D.C.: August 12, 2011.

Value in Health Care: Key Information for Policymakers to Assess Efforts 

to Improve Quality While Reducing Costs. GAO-11-445. Washington, 

D.C.: July 26, 2011.

Medicare: Per Capita Method Can Be Used to Profile Physicians and 

Provide Feedback on Resource Use. GAO-09-802. Washington, D.C.: 

September 25, 2009.

Medicare: Focus on Physician Practice Patterns Can Lead to Greater 

Program Efficiency. GAO-07-307. Washington, D.C.: April 30, 2007.

Related GAO Products

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