Medicare: Certain Physician Feedback Reporting Practices of Private Entities Could Improve CMS's Efforts
Published: 2014-03-26T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.
section_title: What GAO Recommends
paragraphs: 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.

section_title: Letter
paragraphs: 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  patient-centered medical homes.hold teams of providers responsible for all of a patient’s care. They  reward those who coordinate services across providers and make cost- effective referral decisions, among other practices.
Under these arrangements, payers  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. 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.
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. 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, Blue Cross Blue Shield Association, and Network for Regional  Healthcare Improvement to suggest leading organizations that met those  criteria. 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:
Aetna
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
Maine Health Management Coalition
Oregon Health Care Quality Corporation  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   Because nationwide interest in VBP has been largely  beyond our scope.aimed at physician care, we primarily focused our review on performance  reporting to physicians, and as noted, present additional information on  our methodology and findings related to hospital feedback reporting in  appendix I.
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.
subsections: section_title: Background
paragraphs: 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. PQRS applies payment adjustments to promote  reporting by eligible Medicare professionals (EP)—including  physicians, nurses, physical therapists, and others. In 2013, EPs  could report data to PQRS using claims, electronic health records  (EHR) or a qualified registry, 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.
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.
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. 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.
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 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. CMS agreed with our  recommendations, but noted that it was too early to fully implement these  changes.
section_title: Private Entities Selected a Range of Measures and Benchmarks to Assess Physician Group Performance, and Provided Feedback More than Once a Year
paragraphs: 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.
subsections: section_title: Private Entities Focused Their Feedback Efforts on Groups of Primary Care Physicians Practicing within Newer Delivery Models
paragraphs: 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. 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.
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.
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  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,  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.
section_title: Private Entities Decided Which Measures to Report and Compared Physician Performance to Various Benchmarks, Leading to Differences in Report Content across Entities
paragraphs: 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.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.
subsections: section_title: Quality Measures
paragraphs: Private entities generally report on physician quality using many more  process of care measures than outcomes of care measures. 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, a service used to monitor diabetes.
We found wide variation in the number and type of measures in private  entities’ quality measure sets. The total number of quality measures  used in the feedback reports ranged from 14 to 51. 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.)
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.
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.
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.)
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.
section_title: Largely Relying on Claims Data, Health Insurers Spent 4 to 6 Months to Produce Annual Reports and Typically Provided Feedback in the Interim
paragraphs: 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. Some entities supplemented their claims data by  obtaining information from EHRs, patient satisfaction surveys, or chart  extractions. 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.
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, measure calculation, and quality assurance.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.
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.
section_title: Private Entities Generally Offered Access to Additional Report Detail and Other Resources to Help Physicians Improve Performance
paragraphs: 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.
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.
section_title: CMS Feedback Included Group- Determined Physician Quality Measures and Only One Benchmark; CMS Issued Reports Less Frequently than Private Entities
paragraphs: 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.
subsections: section_title: CMS Provided Feedback to Physicians in Groups with 25 or More Eligible Professionals in 2013
paragraphs: 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.
section_title: CMS Feedback Contained Varying Quality but Consistent Cost and Outcomes Measures and Assessed Performance Against a Single Benchmark
paragraphs: 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.
subsections: section_title: Quality Measures
paragraphs: 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.
Web interface. Quality measures under this method pertain to care  coordination, disease management, and preventive services.  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.
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  three measures—such as whether cardiac rehabilitation patients were referred to a prevention program—for at least 80 percent of patients.
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.
section_title: Cost Measures
paragraphs: 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.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.
section_title: CMS Spent 9 Months to Produce the 2013 Feedback Reports, and Did Not Provide Interim Reports
paragraphs: 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. 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  characteristics and complexity, and standardized the cost measures by  removing all geographic payment adjustments. Finally, CMS officials said  they performed data checks to ensure accuracy before the reports were  disseminated.
According to health insurers and collaboratives, physicians find that  frequent feedback enables them to improve their performance more  quickly; however, CMS did not provide physicians interim performance  feedback. 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  advanced data reporting technology, CMS may be able to generate  reports more frequently.
section_title: CMS Included Explanatory Information in Its Reports and Offered Other Resources Online
paragraphs: CMS provided general information on its website and through the  Medicare Learning Network, to assist providers in understanding the  performance feedback and VM. 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.
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.
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.
section_title: Conclusions
paragraphs: 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.
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.
section_title: Recommendations for Executive Action
paragraphs: 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:
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.
section_title: Agency Comments and Our Evaluation
paragraphs: 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  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.
section_title: Appendix I: Private Entity and Medicare Performance Feedback for Hospitals
paragraphs: 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.required CMS to make downward payment adjustments to hospitals   The act also  that did not successfully report certain quality measures. That  downward payment adjustment percentage was increased by the  Deficit Reduction Act of 2005.
The Patient Protection and Affordable Care Act established  Medicare’s Hospital VBP Program for inpatient care provided in acute  care hospitals. Under this program, CMS withholds a percentage of all eligible hospitals’ payments and distributes those funds to high- performing hospitals.
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.
section_title: Appendix II: Quality Measures Used in Sample Physician Feedback Reports Provided by Selected Private Entities
paragraphs: 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.
section_title: Appendix III: Comments from the Department of Health and Human Services
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: 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.
section_title: Related GAO Products
paragraphs: 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.