Medicare Physician Payment: Private-Sector Initiatives Can Help Inform CMS Quality and Efficiency Incentive Efforts
Published: 2012-12-26T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Middle Class Tax Relief and Job Creation Act of 2012 required that GAO examine private-sector initiatives that base or adjust physician payment rates on quality and efficiency, and the initiatives applicability to the Medicare program. This report provides information on (1) common themes among private entities with payment incentive initiatives, and physician perspectives on those themes; and (2) the extent to which CMSs financial incentive initiatives for Medicare physicians reflect such themes. GAO acquired information from nine private entities on 12 initiatives selected from expert referrals to include various sizes, types, and geographic locations. GAO also obtained information from physician groups, state medical societies, and national physician organizations. GAO additionally interviewed CMS officials and reviewed relevant CMS documents.
section_title: What GAO Found
paragraphs: GAO identified several common themes among private entities under review with initiatives that provide incentives for high-quality, efficient care, and selected physician organizations generally support these themes. Specifically:
Private entities generally measure performance and make incentive payments at the physician-group level rather than at the individual-physician level. Physician organizations favor this approach.
Private entities use nationally endorsed performance metrics and noted the need for a standardized set of metrics across all payers. Physician organizations concur that a standardized set of metrics would be less administratively complex.
Most private entities in GAO's study provide financial incentives tied to meeting absolute benchmarks--fixed performance targets--or a combination of absolute benchmarks and performance improvement. Physician organizations prefer incentives tied to absolute benchmarks over those based on how physicians perform relative to their peers. Physician organizations also favored incentives that reward improvement because baseline levels of performance vary.
While private entities' incentive payments vary in size and in method, private entities typically provide such payments within 7 months of the end of the performance measurement period. Physician organizations stated that financial incentives should be distributed soon after the measurement period to have the greatest effect on performance.
The efforts of the Centers for Medicare & Medicaid Services (CMS)--the agency within the Department of Health and Human Services (HHS) that administers the Medicare program--to transform the physician payment system in Medicare reflect, to varying degrees, the themes that GAO identified among selected private entities with physician payment incentives. Specifically, CMS is taking steps to do the following:
Focus on group-level performance measurement and payment adjustments in the Value-based Payment Modifier (Value Modifier) program, designed to adjust Medicare payments to physicians using performance data on the quality and cost of care provided. However, CMS has yet to develop a method of reliably measuring the performance of physicians in small practices in the Value Modifier program.
Apply Value Modifier payment adjustments to outlier physicians--rewarding high performers and penalizing poor performers--using absolute performance targets but not performance improvement. Under this benchmarking strategy, it is likely that only high performers will elect to participate in the program's payment adjustment.
Annually adjust payments through the Value Modifier 1 year after the performance measurement period ends, rather than applying the Value Modifier closer to the time of service delivery. This time lag between performance and payment adjustment may diminish the significance of the incentive to physicians.
section_title: What GAO Recommends
paragraphs: CMS should consider whether certain private-sector practices could broaden and strengthen the Value Modifier program's incentives. Specifically, the agency should consider rewarding physicians for performance improvement as well as for meeting absolute benchmarks, and making more timely payment adjustments to better reflect recent physician performance. Furthermore, the agency should develop a strategy to reliably measure the performance of solo or small physician practices. HHS concurred with all of GAO's recommendations for CMS.

section_title: Letter
paragraphs: Medicare’s ability to control spending remains a serious long-term   Physicians play a central role in the growth of  financial challenge.Medicare expenditures both through the services they provide and the  services they order, including hospital admissions, diagnostic tests, and  referrals to other physicians. Evidence suggests that higher utilization of  these services does not necessarily result in better health outcomes. As  concerns about Medicare solvency have grown, so has interest in  transforming Medicare’s physician payment system to provide incentives  for high-quality care delivered more efficiently.
Physicians in traditional Medicare are paid under a national fee  schedule—with an associated payment rate for each service rendered— in conjunction with a system of spending targets called the sustainable  growth rate (SGR). The Medicare physician fee schedule is updated  annually by the SGR system, with the intent of limiting the total growth in  Medicare spending for physician services over time. Because of rapid  growth in Medicare spending for physician services, the SGR has called  for fee reductions since 2002. However, congressional action has  temporarily averted such fee reductions for 2003 through 2012.  Payments under the physician fee schedule totaled about $67 billion in  fiscal year 2011, accounting for about 12 percent of total Medicare  spending.
Because physicians both directly and indirectly affect total health care  spending, many private health care purchasers, such as insurers, have  initiated programs to reward high-performing physicians and encourage  patients to obtain care from these physicians, and these programs have  evolved to reflect the increased sophistication of payers and providers.  Since the late 1990s, some purchasers have provided financial incentives  to physicians for meeting certain performance measures for quality and  efficiency, an initiative known as pay-for-performance. As these efforts  have evolved, some private purchasers have sought to improve quality  and efficiency using models of coordinated care delivery that may  incorporate elements of an accountable care organization (ACO) or a  patient-centered medical home (PCMH).
In 2007, we reported on various ways that several health care purchasers  profiled the performance of physicians in their networks to draw  comparisons between efficient and inefficient providers, and linked their  performance evaluation results to a range of financial incentives. We  recommended that the Centers for Medicare & Medicaid Services  (CMS)—the agency within the Department of Health and Human Services  (HHS) that administers the Medicare program—start a physician profiling  system with a focus on efficiency to help control Medicare spending. In  2008, the Medicare Improvements for Patients and Providers Act required  HHS to implement a Physician Feedback Program that includes  distribution of confidential feedback reports to physicians on the  resources used to provide care to Medicare beneficiaries, with the option  of including quality measures. In 2011, we reported on CMS’s efforts and  the challenges that the agency faced in developing the methodology and  distributing physician feedback reports. In 2010, the Patient Protection  and Affordable Care Act (PPACA) directed HHS to establish a Value- based Payment Modifier (Value Modifier) program under which Medicare  physician payments are to be adjusted for quality and efficiency of care.  HHS is required to phase in the Value Modifier beginning in 2015 and  plans to do so using performance data derived from the Physician  Feedback Program; it is required to cover all physicians under the Value  Modifier program by 2017. PPACA also established a number of  coordinated care delivery models and gave CMS the authority to test  others through its Innovation Center.
The Middle Class Tax Relief and Job Creation Act of 2012 required that  GAO examine private-sector initiatives that base or adjust physician  payment rates on quality and efficiency and assess their applicability to  the Medicare program. To meet this requirement, this report provides  information on (1) common themes among private entities with initiatives  that offer payment incentives for high-quality, efficient physician care, as  well as physician perspectives on those themes; and (2) the extent to  which CMS’s financial incentive initiatives for Medicare physicians reflect  such themes.
To identify common themes among private entities with payment  incentives for high-quality, efficient physician care, we obtained  information from nine private entities that conduct 12 prominent initiatives.  (See table 1.) To identify such entities, we interviewed academic and  industry experts on physician performance measurement and payment  reform. We also reviewed health care policy research literature and a  transcript from CMS’s National Provider Call organized to provide input  on best practices from pay-for-performance in the private sector. The  private entities identified from these sources vary by geography, size, and  type, and have initiatives that include pay-for-performance, PCMH, and  ACO models. The initiatives referenced in this report are sponsored by  two national health plans, three Blue Cross Blue Shield plans, one  multistate plan, two substate plans, and one multistakeholder association,  comprised of health plans, physician groups, and hospital systems,  among others. The themes that we discuss in this report reflect the  initiatives of the nine entities we studied and may not be generalizable to  all private entities that provide financial incentives to physicians for quality  and efficiency. Also, we did not conduct independent analyses of the  effectiveness of the incentive initiatives.
To obtain physicians’ perspectives on the common themes that we  identified, we interviewed physician groups associated with particular  initiatives and other organizations representing physicians with  knowledge of the initiatives. The physician groups varied in size—with  as many as 1,600 physicians—and structure. We spoke with physician  leaders of two independent practice associations, a large primary care  group practice, medical staff at a hospital, and an alliance of medical  groups. We also spoke with representatives of three state medical  societies and a state professional association representing physician  organizations. Additionally, we reviewed comment letters submitted by  national physician organizations, including the American College of  Cardiology and the American Medical Association, in response to CMS’s  proposed rule regarding Medicare incentive payments for quality and  efficiency. The perspectives that we discuss in this report reflect those  physicians groups or organizations whose comments we sought or  reviewed and may not be generalizable to all physicians.
To examine the extent to which CMS’s financial incentive initiatives for  Medicare physicians reflect the common themes among private entities  that we identified, we reviewed the agency’s 2013 revisions to payment  policies under the Medicare physician fee schedule final rule, which  addressed implementation of the physician Value Modifier and finalized  CMS’s overall approach.officials and examined relevant CMS documents.
We also conducted interviews with agency  We conducted this performance audit from April to December 2012 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: Because Medicare pays for a large share of health care throughout the  country, its size and market power can help it to lead payment reforms in  the rest of the health care system. Its use of financial incentives for  reaching performance targets can, in effect, set standards that private  payers may adopt. However, statutory requirements for the Medicare  program limit the types of changes that CMS can implement. For  example, Medicare must pay for health care delivered by any eligible  physician willing to accept Medicare payment and follow Medicare  requirements, and must pay uniform Medicare rates to all physicians.  Therefore, unlike private health care purchasers, CMS cannot exclude  poor-performing providers from participating in the program and cannot  negotiate different reimbursement rates with different providers.
In recent years, in response to legislation, HHS has taken steps to  transition Medicare physicians from a fee-for-service system in which only  the volume of services is rewarded, to one in which value—as measured  by the quality and the efficiency with which that care is delivered—also  determines payment. CMS has worked with physician groups in designing  and implementing the following physician initiatives, among others.
Physician Quality Reporting System (PQRS). PQRS collects  physician-reported data on quality measures for covered services  furnished to beneficiaries. CMS provides an incentive payment to  physicians who satisfactorily report quality data. The agency  announced that, in 2013, physicians who do not satisfactorily meet  PQRS submission requirements will have their fee schedule amount  reduced by 1.5 percent for services furnished in 2015.
Value Modifier Program. PPACA directed HHS to establish a Value  Modifier to adjust Medicare payments to some physicians in 2015 and  to all physicians in 2017 on the basis of the quality and cost of care  provided. To develop the Value Modifier, CMS plans to use  performance information on quality and cost metrics derived from  Medicare claims and data submitted under PQRS. Because the  Value Modifier program must be budget neutral, upward adjustments  will depend on the total sum of negative adjustments in a given year.
Shared Savings Program. CMS has finalized rules under which  physicians, hospitals, and other health care providers may work  together to better coordinate care for Medicare beneficiaries through  an ACO. While individual physicians continue to be paid under the  Medicare fee schedule, the agency plans to develop a benchmark for  each ACO against which its performance is measured to assess  whether it qualifies to receive shared savings or in some cases be  held accountable for losses.
Comprehensive Primary Care Initiative and Multi-Payer Advanced  Primary Care Practice. Eligible primary care practices may receive  shared savings rewards under some of CMS’s demonstrations related  to operating a PCMH. Under the Comprehensive Primary Care  Initiative, CMS intends to pay 500 primary care practices in seven  markets for improved and comprehensive care management, and  after 2 years offer them the chance to share in any savings they  generate. For the Multi-Payer Advanced Primary Care Practice  demonstration, CMS intends to award payment incentives through  existing PCMH initiatives that are currently being conducted by states  to make medical home practices more broadly available.
Physician Compare Website. This Internet tool serves as a directory  for beneficiaries, allowing them to search for a physician by specialty,  location, hospital affiliation, and other factors. The profile pages also  indicate if a physician satisfactorily participated in the PQRS. PPACA  requires that CMS make quality and patient experience measures  publicly available on the website by January 1, 2013. Publishing  comparable performance results can encourage physicians to  improve their performance in order to attract more beneficiaries.
These legislated changes, along with market forces, have potential  implications for the way many physicians practice. For example, emerging  delivery models such as ACOs may lead physicians to join larger groups,  more closely align with hospitals, and take on financial risk for managing  patient care. Although many physicians who serve Medicare beneficiaries  work in small practices, more are increasingly employed by hospitals and  health care systems. As of 2008, nearly one-third of U.S. physicians  worked in solo or 2-physician practices, 15 percent worked in groups of 3  to 5 physicians, 19 percent worked in practices of 6 to 50 physicians, and  13 percent practiced in hospital settings. However, a 2011 study found  that physicians are increasingly selling their practices or seeking  employment directly with healthcare systems, and hospitals are  aggressively acquiring physician practices to remain competitive.
section_title: Common Themes among Private Entities Pertain to Performance Measurement and Incentive Payment; Physician Organizations Largely Concur with These Themes
paragraphs: We identified several common themes among private entities with  physician payment initiatives in our study. These included the importance  of focusing on physician groups rather than individual physicians, the  desire for a standardized performance measurement set, the use of  absolute performance and improvement targets, the timely distribution of  incentive payments, an emphasis on care coordination to improve quality  and efficiency, and the use of other strategies to improve quality and  efficiency. For the most part, physician organizations familiar with these  themes expressed their support.
subsections: section_title: Stakeholders Largely Agreed That Performance Measurement and Incentive Payment Should Be at the Physician-Group Level
subsections: section_title: Private Entities
paragraphs: Private entities in our study generally based incentive payments on the  performance of physician groups rather than individual physicians largely  because of methodological issues and the importance of reinforcing  group-wide accountability. Most of the private entities we spoke with  pointed out that individual-level measurement often does not generate  sufficient performance data to produce credible results. For instance, for a  condition-specific performance metric, a physician may see too few  patients with the relevant condition to be measured reliably. Integrated  Healthcare Association (IHA) noted that using physician organizations as  the unit of analysis in the California Pay-for-Performance (CA P4P)  program helps to overcome small sample sizes that impede valid  measurement of efficiency at the individual physician level, although  sometimes even sample sizes at the physician organization level may not  be adequate. A representative at Blue Cross Blue Shield of Michigan  (BCBS MI) stated that this methodological issue is especially relevant  when measuring performance in specialty care practices. Because  subspecialists may provide distinct services within their specialties, they  can look like outliers when compared with their specialty peers at the  individual level. Several private entities told us that group-level  measurement also promotes group-wide accountability. For example,  representatives at Dean Clinic said that measuring performance at the  group level allows each of its clinical divisions to leverage each  physician’s strengths, and keeps them engaged in performance  improvement. In addition, BCBS MI believes that group-level  measurement and payment may prevent physicians with particularly  complex patients from being resistant to participating in the initiative.
Because many primary care physicians work in small, independent  practices, CareFirst BlueCross BlueShield (CareFirst) PCMH program  has developed a strategy for including them in its initiative. CareFirst  physicians do not need to be a part of a formal medical group to  participate in the program. Rather, they may organize voluntary, “virtual”  panels for the purpose of performance measurement and incentive  payments. Established physician groups may also participate, provided  that they form subgroups of between 5 and 15 physicians—the panel size  requirement for participation. As an incentive to join the program,  CareFirst increases the fees paid under its physician fee schedule by   12 percentage points. It offers additional financial incentives to physician  panels for bringing care costs within a budget target and for improving  quality on a variety of metrics. CareFirst representatives believe that the  primary care physician is in the best position to comprehensively  understand a patient’s needs—in particular, the needs of chronically ill  patients—but that no one physician has a large enough patient pool for  reliable performance measurement. They said that not only does panel  formation allow for reliable performance measurement, but it also  provides a structure for peer pressure given that all physicians in a panel  have an economic stake in high performance.
Many of the private entities we spoke with were also consistent in their  view that it is the responsibility of physician group management to drive  individual physician performance improvement. Therefore, they not only  provide physician groups with feedback reports at the group level, but  most also provide supporting data at the individual physician level that  can be used to generate individualized physician feedback reports. For  example, under the Alternative Quality Contract (AQC), Blue Cross Blue  Shield of Massachusetts (BCBS MA) sends performance data and reports  in electronic format to each physician group’s central leadership, who are   Similarly,  responsible for sharing the results with individual physicians.under the Physician Group Incentive Program (PGIP), BCBS MI expects  physician organizations to create appropriate reports at the practice unit  and individual physician level to identify areas for improvement, as well as  to track performance over time and guide focused system-transformation  and performance improvement interventions. Some entities noted that  peer pressure and competition within an organization can provide an  incentive for physicians to improve their relative performance. For  example, Rocky Mountain Health Plans shares relative performance data  on resource use with certain physicians to facilitate communication about  clinical quality and cost. Also, Dean Clinic representatives mentioned that  reporting performance at the individual level within each specialty division  instills peer pressure, which can help facilitate the improvement process.
Furthermore, many private entities we spoke with said that physician  groups have complete discretion over how their incentive payments are  used and therefore may not distribute their entire incentive payments to  frontline physicians. For example, BCBS MI reported that, in general,  physician groups distribute roughly one quarter of PGIP incentive  payments directly to front-line physicians, and invest the remainder in  systems improvements that benefit the practices and the physician group.  Several other private entities also stated that physician group managers  use their incentive payments for shared practice improvements, such as  investing in new or additional information-technology capabilities, hiring  case managers, and rewarding nonphysician staff. A BCBS MA  representative noted that physician groups undertake these types of  shared practice investments to help make the improvements in care  quality and efficiency called for in the AQC.
Physician organizations in our review agreed that measurement at the  physician group level for incentive pay is statistically more accurate than  measurement at the individual physician level. They noted that one  physician is unlikely to have a patient population large enough for  statistical reliability, making it difficult for private entities to validate  individual physician-level data. They also said that attributing patients to  one physician for measurement purposes is difficult because physicians  often work as a team to provide care. On the other hand, they noted that  physician groups are likely to have the patient sample sizes needed to  ensure accurate calculations and minimize the attribution problem.  According to a letter to CMS from the American College of Cardiology,  the physician group level provides sufficient data to ensure statistical  significance but is still a level at which individual physician actions can  improve quality.
Physician organizations in our study also agreed that it is their  responsibility to drive individual physician performance improvement.  They noted that when private entities provide information on individual  physician performance, managers can develop tailored physician  feedback reports using their own analytical tools. For example, physician  groups can use the performance reports they receive internally to  aggregate data across their entire patient population. They told us that  these reports can be helpful because physicians are inclined to trust the  data provided by their groups’ managers, react to internal peer pressure,  and want to examine their entire patient population.
In addition, physician organizations we contacted cited different  approaches for distributing financial incentives. For example, Mesa  County Physicians Independent Practice Association (IPA), Inc., receives  incentive payments on a quarterly basis from Rocky Mountain Health  Plans. It then pays its physician practices, each of which may decide to  distribute the incentive payments in a different manner. Some physician  practices in the IPA distribute the money equally to individual physicians;  others distribute the money to individual physicians on the basis of their  relative performance scores; and still others retain the money for capital  improvement projects. A different approach is that used by ProHealth  Physicians, Inc. (ProHealth), a 200-member physician group in Cigna’s  Collaborative Accountable Care (CAC) initiative. ProHealth reported  setting aside a portion of the incentive payments to cover personnel and  overhead costs associated with administering the initiative. About half of  the remainder is distributed to individual physicians on the basis of their  performance, with the highest performers receiving the most money and  the lowest performers receiving no money. The rest of the incentive  payment is considered profit and may be paid to its physician  shareholders.
section_title: Private Entities Select from among Nationally Endorsed Metrics; Stakeholders Noted the Need for a Standard Set of Metrics across Payers
subsections: section_title: Private Entities
paragraphs: In choosing performance metrics for their initiatives, the private entities  we interviewed largely draw from those nationally endorsed by such  groups as the National Quality Forum (NQF), which has endorsed over   Many of the entities cited difficulties in developing sound  700 metrics.quality metrics for their initiatives as the reason for selecting nationally  endorsed metrics. However, some entities in our study supplement  nationally endorsed quality-of-care metrics with others. For example, a  representative of BCBS MA told us that, in collaboration with physicians,  experimental measures can be used to provide evidence on the sample  size needed to generate reliable data for certain measures. Physician  organizations participating in BCBS MA’s AQC have the opportunity to  work on the development of up to three experimental measures of their  choosing each year on the basis of a list provided by the health plan. The  rest of the AQC metrics are largely NQF-endorsed and are supported by  entities such as CMS or the National Committee for Quality Assurance  (NCQA). To measure efficiency of care, many entities reported using a  risk-adjusted total cost of care metric that captures all services provided  to physicians’ entire patient population. HealthPartners, for one, uses its  own NQF-endorsed total cost of care and resource use metrics calculated  on a per-member basis to help identify potential overuse and underuse of  services. Some private entities measure efficiency through metrics that  are more specific than total cost of care. For example, Dean Health Plan’s  Practitioner Incentive Model has efficiency metrics that include generic  drug prescription patterns and emergency room visits per 1,000  members, a metric also used by CMS for Medicare beneficiaries.
While NQF fosters agreement on national standards for measuring health  care performance, no national consensus exists on a single best set of  quality metrics. Most private entities that we spoke with were in  agreement that use of a standardized set of performance metrics across  payers would be ideal. Standardization may include uniformity in the  metric selected, the benchmark against which performance is assessed,  and the relevant patient population. As expressed by HealthPartners representatives, a standardized set of metrics would send strong and  consistent messages to providers, and make it easier for physician  groups to focus on defined areas for quality improvement. California’s IHA  accomplished this by arranging for its health plans and physicians to work  together to develop a uniform but dynamic set of performance metrics for  statewide use. IHA reported that, until then, California physicians found it  challenging to focus on performance improvement when many health  plans provided incentives based on different metric sets. As of 2011, the  CA P4P metric set included 85 metrics related to clinical quality, patient  experience, meaningful use of health information technology, and  appropriate resource use.
Several of the private entities in our study commented on the dearth of  reliable specialty care metrics. For example, a representative from  UnitedHealth Group noted inconsistency in the number of quality metrics  across specialties. Nevertheless, most private entities that we spoke with  included specialists in their incentive initiatives despite their limited  performance data. Dean Clinic representatives discussed how they  created a list of specialty care metrics for their pay-for-performance  program in collaboration with their physicians. Over the course of 1 year,  they offered each care division the opportunity to develop relevant,  specialty-specific metrics, a process described as resource-intensive. To  be formally adopted, these metrics required consensus among physicians  that the new metrics applied to the majority of specialists within that  department, and they had to be measureable through billing or electronic  health record data. For example, physicians in the cardiovascular surgery  division are measured on the percent of cardiovascular surgeries  performed without a blood transfusion. Dean representatives surmised  that, if a similar process were undertaken at the national level—whereby  CMS would ask each specialty society to agree on 5 to 10 clinically  relevant measures—it could be a step towards developing a robust,  standardized set of metrics for specialty care.
Physician organizations in our review indicated that they generally prefer  quality metrics that have been endorsed by national groups, but are open  to the inclusion of experimental metrics. They stated that standardization  across payers would reduce the administrative burden associated with  tracking distinct requirements of multiple metric sets among various  initiatives. For example, a physician leader at ProHealth reported that,  among the 21 value-based payment initiatives in which ProHealth  participates, private insurers vary not only by which metrics are selected  but by how the metrics are used. Representatives of the Massachusetts  Medical Society added that, as a result, physicians may become  overwhelmed and may not spend time to distinguish differences between  the components of each initiative. Physician organizations also noted that  some experimental metrics used in private-entity initiatives can be useful  for filling in clinical areas that lack strong nationally endorsed metrics,  although others may lack a significant medical rationale or be difficult to  measure.
Furthermore, physician organizations in our study noted the importance of  using specialty-specific metrics to ensure that performance is accurately  attributed to specialty care providers for the care they furnish. To develop  relevant metrics for specialty care providers, the Mesa County Physicians  IPA organizes a team of local physicians each year to create more  metrics for specialty care on the basis of new clinical evidence, similar to  a process done for primary care metrics. However, according to a letter to  CMS from the American Medical Association, value-based payment  initiatives do not currently include all medical specialties because the  tools for distinguishing value across specialties are inadequate. National  medical societies have taken action to meet the need for more specialty  metrics. For example, according to letters to CMS from national physician  organizations, the Community Oncology Alliance has identified 16 key  metrics of quality and value in cancer care delivery, and the American  Association of Orthopaedic Surgeons has identified metrics for total knee  replacements.
section_title: Private Entities Largely Reward Physicians for Meeting Absolute Targets and Improving Performance, an Approach That Physicians Favor
subsections: section_title: Private Entities
paragraphs: Most private entities in our study base financial incentives on absolute  performance targets or a combination of absolute targets and on  improvement over time. Absolute targets are fixed and known to their  physician groups during the performance measurement period, offering  greater certainty regarding the efforts required to become eligible for  payment. As such, they serve as a guide for high performers to maintain  their quality and efficiency standings. Some entities reward physicians on  a set of graduated absolute targets, whereby higher performance within  the set of targets receives a greater reward. For example, under the AQC,  physician groups are rewarded on the basis of performance targets (or  “gates”) between 1 and 5. On a measure of colorectal cancer screening  for members aged 51 to 75 years, AQC physician groups achieving a  screening rate of roughly 65 percent met the minimum (“gate 1”) level of  good performance on that measure, while those who screened about   83 percent met the maximum (“gate 5”) level of performance on that  measure. Aggregating “gate” scores across the roughly 5 dozen  measures in the AQC contract determines the overall performance and  quality incentive payment. The effectiveness of the absolute  benchmarking approach in motivating providers depends on where the  performance targets are set. If the target is set too high and perceived to  be too difficult to reach, physicians may not respond to the incentive. If it  is set too low, the entity will be making incentive payments for  performance already being delivered and will not encourage  improvement.
Several private entities in our study combine absolute performance  targets and improvement over time in their benchmarking strategies.  Benchmarking based on performance improvement provides an incentive  for lower performers as well as higher performers, as it rewards the gains  achieved since past performance. Under the CA P4P program,  performance on each metric is typically assessed against absolute  targets—set at the 75th and 95th percentiles for the program in the  previous year—and on improvement—closing the gap between the  group’s previous year performance score and the 95th percentile of the  previous year’s target. IHA representatives told us that, as of 2012, six of  the seven health plans in the CA P4P program have adopted this  benchmarking methodology.
Some of the entities we spoke with reward high relative performance  along with improvement. Using a relative benchmark approach,  physicians do not know their numerical target at the start of the  performance period because their benchmark is based on the future  performance of their peers. None of the entities we spoke with based  incentive payments exclusively on relative performance. For instance,  physician groups in Cigna’s CAC initiative must perform at a rate equal to  or above the market average for each quality metric, or they must show  improvement in their rate.
Physician organizations in our review preferred tying incentives to  absolute performance or improvement rather than relative performance.  Some organizations saw merit in rewarding physician groups for  achieving high performance rates; others favored incentives based, at  least in part, on improvement because not all physician groups are at the  same starting point. Selected organizations cautioned against using  relative benchmarks, asserting that without prior knowledge of the level of  performance needed to earn incentive pay, physician groups might not be  willing to participate in an incentive initiative. Regardless of which  benchmarking approach is used, frontline physicians might not know all  the details of the incentive initiatives they work under. According to  representatives of the Massachusetts Medical Society, frontline  physicians likely know the performance targets that the physician group’s  management sets but may not be aware of key details of payers’  incentive structures, such as the thresholds for achieving a higher  incentive payment under BCBS MA’s AQC initiative.
section_title: While Private Entities Offered Varied Payment Sizes and Methods, Physicians Say Timeliness Can Enhance the Incentive
subsections: section_title: Private Entities
paragraphs: The incentive payments under the initiatives we reviewed varied in their  size and method, but were similar in their timing. The size of payment  incentives reported to us ranged from around 2 percent to over 20  percent of annual pay, with most initiatives offering at least 5 percent of  annual pay in incentives. Several private initiatives in our study provide an  incentive of at least 10 percent of annual physician revenue. We found  three general methods used to make incentive payments:
Some initiatives’ incentives allow physicians to earn a percentage  add-on to a fee schedule. Physicians can only benefit from meeting  quality and cost targets under this type of incentive; if they fail to meet  those targets, physicians would still receive the full fee-for-service  payment. Generally, in such cases, the payer is at risk for high costs,  not the physicians. For example, on the basis of primary care  physicians’ overall cost and quality performance, CareFirst’s PCMH  program offers a potential increase of 20 to 60 percent in its fee  schedule.
Other initiatives implement the incentive through a bonus, such as a  per-member-per-month bonus payment, which also does not carry  significant physician risk. Cigna’s CAC provides high- and improved- quality performers with a periodic per-patient payment, adjusted by  the physician group’s effect on the trend of total medical cost. BCBS  MI’s PGIP has an incentive pool that provides for a bonus payment  depending on performance on specific subinitiatives in which  participating physician organizations choose to participate.
Still other initiatives implement the incentive payment through a  withhold—whereby a portion of the payment due to a physician is  withheld until the status of their performance is determined at the end  of the measurement period. The amount withheld is returned only to  physicians who meet performance targets, putting some cost risk on  the physicians. HealthPartners representatives told us that their  Partners in Progress program applies a withhold from market-based  payment that can range from 1 to 5 percent of revenue. Under Rocky  Mountain Health Plans’ incentive program, physician groups negotiate  with the health plan to determine the amount withheld.
In addition to providing bonuses to physician organizations, BCBS MA’s  AQC provides incentives to physician organizations through global  budgets. Under a 5-year contract, each participating physician  organization begins with a fixed budget that covers costs for all patient  care on the basis of the population it serves; annual adjustments are  made to manage the risk faced by the physician organization, such as  adjustments to account for any changes in patient population health  status. Physician organizations share any money with BCBS MA that is  saved by spending less than the budgeted amount for the patient  population, but they also share the risk when more money is spent than is  budgeted. BCBS MA also rewards physician organizations with a per- member per-month bonus for high performance as compared with fixed  targets on a set of quality metrics.
The private entities in our study generally distributed incentive payments  to physician group managers during the year immediately following the  performance period. Specifically, most private entities paid incentives  within 7 months of the end of the performance period. For instance,  BCBS MI distributes PGIP incentive payments to physician organizations  2 months after the end of the 6-month performance period. BCBS MA  provides AQC groups interim incentive payments monthly, and these  payments are reconciled during the year after the annual performance  period ends to reflect actual performance.
According to the physician organizations in our review, the  responsiveness of physicians to payer initiatives is often tied to the size,  method and frequency of the incentive payment. Regarding the  appropriate size of the incentives, physician organizations noted that the  larger the potential payoff, the larger their performance improvement is  likely to be. Although financial considerations are not the sole motivation  for seeking high performance, physician organizations said they would  like incentive payments to cover the costs of participating in the  initiative—including the cost of data collection and the cost of improving  performance.
Physician organizations in our review generally found the various types of  incentive payments to be fair and useful from a management perspective.  For instance, MedChi, the Maryland State Medical Society, reported that  physicians are attracted to CareFirst’s PCMH add-on to the fee schedule  because it provides up-front capital that could be used to enhance  productivity. In addition, according to a physician leader at ProHealth, the  per-member per-month incentive payment under Cigna’s CAC initiative  helps with forecasting revenue and planning infrastructure improvements.  Finally, representatives from the Mesa County Physicians IPA said that  the withhold incentive structure established by Rocky Mountain Health  Plans’ Incentive Program works to keep physician groups attentive to  performance improvement by knowing that some payment is at risk.
From the physicians’ perspective, timely incentive payment cycles from  private entities can be helpful for monitoring and adjusting performance.  Physician organizations included in our review stated that incentive  payments should be distributed soon after the achievement of  performance to make the most difference. They noted in letters to CMS  that, if an incentive is paid out very infrequently or if there is not a good  understanding of how performance relates to incentive payment, it is  unlikely to motivate improvement.
section_title: Private Entities Support Care Coordination with Additional Resources and Performance Metrics; Physicians Say Plan- Provided Data Help Coordinate Care
subsections: section_title: Private Entities
paragraphs: A common element of most private entities with incentive initiatives is providing support to physicians for certain care-coordination activities.We found that several private entities fund or partially offset the costs of  ancillary providers—such as health coaches or nurse coordinators—who  furnish care-management services to patients with certain health  conditions. CareFirst’s PCMH, for one, hires local nurse coordinators and  compensates physicians for preparing and monitoring care plans for  certain patients. Physicians receive $200 for each care plan created— working with CareFirst’s nurse coordinators to identify patients with  multiple chronic diseases—and $100 periodically to review and update  those care plans. Private entities in our review that provide financial  support for care management may increase physician office visit fees or  make up-front payments to physicians for care coordination. As a key  element of its CAC initiative, Cigna provides physician groups with an up- front care-coordination payment, which helps support nurse care  coordinators charged with reaching out to and coordinating the care for  patients who have been identified as at risk for hospital readmissions or  who have gaps in care.
Some private entities we spoke with explicitly address care coordination  in their performance measurement sets. For example, CA P4P uses a  “care transitions” metric to assess whether physician groups have  systems in place to follow up with a patient after laboratory tests and  imaging services, as well as a care-coordination outcomes metric related  to hospital readmissions. In addition, CareFirst’s nurse coordinators are  responsible for monitoring physicians’ performance on metrics related to  physician–patient engagement as a measure of physician groups’ ability  to provide coordinated care. Many private entities reported that they  provide physicians participating in their initiatives with information on gaps  in care. UnitedHealth Group provides physicians with access to a web- based portal that uses claims data to identify gaps in care and  opportunities for improvement. The portal identifies patients who may be  due or overdue for preventive services or other health care services.
In addition to receiving financial support, physician organizations in our  review approved of other efforts by private entities to advance care  coordination. According to Massachusetts Medical Society  representatives, physician groups have used data from insurers and other  sources to target patients who would benefit most from care coordination.  For example, a physician group reviews the data during weekly meetings  where a clinical team discusses each physician’s list of patients and  determines whether patient follow-up is needed. Similarly, ProHealth case  managers use data from Cigna to schedule follow-up appointments, focus  on care transitions, and serve as liaisons to Cigna’s nurse care  coordinators. Selected organizations noted that such care coordination  has the potential to both improve patient outcomes and moderate cost  growth.
section_title: Some Private Entities Publicly Report Metrics and Use Tiered Networks, but Physician Organizations Generally Oppose These Mechanisms
subsections: section_title: Private Entities
paragraphs: Several private entities in our study augment their payment initiatives with  other strategies that offer physicians incentives to improve quality and  efficiency:
Some private entities report physician group performance results  publicly. IHA publishes information on many CA P4P metrics on the  state’s Office of the Patient Advocate website. It cited a survey of  physician organizations by a P4P program evaluator indicating that  public reporting may motivate physician organizations to improve  performance as much as, or more than, the financial incentives.
Some private entities use tiered physician networks as an incentive  for patients to seek care from physicians deemed to be higher quality,  more efficient, or both. Members who use physicians assigned to a  high-quality, low-cost provider tier may receive a modest reduction in  their coinsurance. A Cigna representative told us that tiered network  options are available in all of its major markets. Individual physicians  and physician groups can be designated as high quality and efficient  on the basis of performance provided that they meet Cigna’s required  thresholds for patient sample size.
UnitedHealth Group conducts a Premium Designation program to  distinguish those physicians—and physician groups, by specialty— who deliver higher-quality and more-efficient care from other  physicians or physician groups. UnitedHealth Group representatives  noted that, although this program does not necessarily lead to lower  cost sharing, it is designed to enhance transparency for plan  members, which in turn may motivate physician performance. When a  physician does not have a large enough sample size for reliable  measurement, this is noted in the public designation displays.
Physician organizations in our review noted that physicians generally  oppose public reporting and network tiering but may respond positively to  other nonpayment incentives. They cautioned against publicly reporting  performance at the individual physician level because of data reliability  and methodological concerns. In addition, according to representatives  from the Massachusetts Medical Society, physicians in the state also are  generally against network tiering in part because of concerns related to  arbitrary thresholds based on relative performance and inaccurate  information from claims data. However, selected organizations noted that  using peer pressure within a physician group, reducing administrative  burdens associated with participating in incentive initiatives, and  improving the technological capabilities of physician groups could help  increase the quality and efficiency of care.
section_title: CMS’s Efforts to Tie Physician Payments to Quality and Efficiency Reflect, to Varying Degrees, Common Themes of Private Entities with Physician Payment Initiatives
paragraphs: CMS’s efforts—particularly through the Value Modifier program—to  reform the Medicare physician payment system reflect, to varying  degrees, the common themes we identified among private entities with  physician payment initiatives. CMS is moving toward broader physician  group-level performance measurement, but this level of measurement  does not currently apply to small-practice physicians in the Value Modifier  program. According to CMS, the agency is taking steps toward  standardizing performance metrics across its programs and continues to  solicit specialty care metrics. In its Value Modifier benchmarking strategy,  CMS plans to tie physician incentives to absolute benchmarks, but not to  performance improvement. It also plans to initially provide small  downward fee adjustments to participating low performers and budget- neutral fee increases to participating high performers, but these  adjustments will occur a year after the performance period ends.  Additionally, CMS has recently taken action to promote greater care  coordination and publicly report physician performance.
subsections: section_title: CMS Has Taken Steps to Expand Physician Group- Level Measurement, but Plans for Measuring Small Practices at This Level Remain Undeveloped in the Value Modifier Program
paragraphs: CMS has taken a number of steps toward broader physician group-level  measurement for incentive payments. The agency recently announced it  would modify its performance data collection by easing PQRS reporting  requirements for physician groups. Because many physician practices  report performance data as individual providers, CMS has sought to  promote physician group-level reporting by making PQRS group-reporting  requirements more flexible. In 2013, CMS intends to give physician  groups the option of having CMS calculate quality metrics from claims  data. In addition to administrative claims-based reporting, CMS plans to  offer alternative ways to meet group PQRS reporting standards, including  through a web-based interface.
In addition, CMS intends to initiate the Value Modifier at the group level  and has expanded the number of ACOs serving Medicare beneficiaries.  Starting in 2015, CMS plans to apply the Value Modifier to claims  submitted by physicians in groups with 100 or more eligible professionals  that bill Medicare under a single Tax Identification Number (TIN). CMS  stated that incentives paid under a physician group TIN not only allow for  more reliable measurement than at the individual level, but elevate the  importance of the group in which a physician practices—since each  physician in the group receives the same payment modifier. In addition,  CMS has increased the number of physicians who are eligible for  incentive payments at the group level by adding to the number of ACOs  under contract. After initially signing 65 ACOs as of April of 2012, CMS  now contracts with 153 ACOs that serve more than 2.4 million  beneficiaries, and the agency accepts new ACO applications annually.
Although these steps are designed to raise the number of physicians  whose performance will be measured at the group level, CMS has not yet  developed a method of reliable measurement for physicians in small  practices in the Value Modifier program. Without such a method, the  agency will likely measure those in small practices at the individual level  in 2015, the performance year likely to determine the application of the  Value Modifier for all physicians in 2017. According to CMS, the decision  not to initially apply the Value Modifier to established groups of less than  100 eligible professionals stemmed from concerns regarding untested  cost metrics and administrative complexity. For instance, CMS reported  that allowing physicians to be measured as an informally defined group  would require the agency to establish and maintain additional group  identifiers that would not as easily account for organizational changes.  While CMS has reported that the agency intends to assess the possibility  of allowing the aggregation or disaggregation of TINs in future years, it  has not outlined a strategy to reliably measure the performance of the  majority of physicians—those in small practices. According to CMS  officials, among physicians that serve Medicare fee-for-service  beneficiaries, more than two-thirds currently practice in groups of less  than 25 individuals.
CMS officials stated that they do not plan to direct recipients on how to  use incentive payments. Agency officials said there are no requirements  for physician groups to use incentive payments for any particular  purposes. In the case of ACOs, CMS asks applicants to identify how they  plan to use payments to achieve the goals of the Shared Savings  program—higher quality and lower cost—but it has not been prescriptive  on how ACOs can use their shared savings.
section_title: CMS Has Begun Standardizing Metrics and Seeking Ways to Better Measure Specialty Care
paragraphs: According to CMS officials, the agency is taking steps to both develop a  standard set of metrics across its programs and enlarge the number of  specialty care metrics in use. By 2014, the agency intends to further align  the metrics in its Electronic Health Record (EHR) Incentive,Savings, and Value Modifier programs. By incorporating metrics that are  endorsed by entities such as NQF, CMS’s claims-based metrics may   Shared  align with many private-sector programs as well.ways to increase metrics for specialty care. For example, agency officials  said that while they do not formally task specialty societies with  developing measures specifically for PQRS, they annually solicit input on  metrics from stakeholders, including medical specialty societies.  Furthermore, CMS is considering allowing metrics that have been  developed, collected, approved, and vetted by specialty societies to be  reported on the Physician Compare website. The agency could potentially  choose to include these specialty metrics in PQRS.
section_title: CMS to Target Outlier Performers and Use Absolute Benchmarks but Not Reward Improvement under Value Modifier Program
paragraphs: CMS plans to implement the Value Modifier by providing incentives only  to physicians determined to be performance outliers on the basis of  benchmarks using absolute targets based on existing performance, but  not performance improvement. Beginning in 2013, physician groups with  100 or more eligible professionals that meet PQRS reporting standards  can either elect to have their 2015 Medicare payment modified under a  quality tiering approach or choose to effectively not have their payment  modified at all. For physician groups that select the quality tiering  approach, only those with outlier scores in either quality or cost would be  eligible for a payment adjustment; those in the highest tier would  potentially see an increase in their payments under the fee schedule and  those in the lowest tier would potentially see a reduction.group scores would be a composite derived from performance relative to  the prior year national average for each applicable quality metric; cost   Physician  would be measured using current year comparisons. Physician groups  with low quality or high cost scores in a prior period will not be rewarded  for either graduated levels of performance or improving their  performance. CMS officials reported that the agency does not plan to  consider rewarding performance improvement in the Value Modifier until  more physicians participate in PQRS, and thus provide the agency with a  more reliable understanding of how to set targets. However, until then,  CMS’s benchmarking strategy will make it less likely that many physicians  will choose to put a portion of their payment at risk through the Value  Modifier program. Because of current incentives, the quality tiering  approach is likely to encourage participation only by those groups of  physicians with high prior scores.
section_title: Value Modifier to Start Small with Fees Adjusted Annually, 1 Year after the Performance Period Ends, Rather Than More Frequently
paragraphs: Agency officials reported that CMS plans to initially set the size of the  Value Modifier fairly low. Medicare physicians participating in the quality- tiering approach of the Value Modifier program could potentially receive a  downward adjustment of as much as 1 percent or an upward adjustment  of up to two times a budget-neutral factor. (See table 2.) Because CMS’s  Value Modifier program must be budget neutral, upward adjustments are  multiplied by a factor derived from the sum total of negative adjustments  for both low performers and non-PQRS reporters. CMS officials told us  they would like to receive performance data from the majority of  physicians before considering any increase to the magnitude of the Value  Modifier. The agency stated that it does not want to initially apply a  greater downward payment adjustment for the low-quality/high-cost  physician groups opting for the quality-tiering approach than that of  nonsatisfactory PQRS reporters (1.5 percent in 2015).
Moreover, to meet the budget-neutrality requirement for the Value  Modifier, CMS decided to help fund participating high performers’  payment incentive by imposing an automatic downward adjustment of   1 percent for non-PQRS reporters.adjustments for physicians with significantly poor performance or who do  not meet performance reporting standards are CMS’s sole funds to  increase the size of its performance incentive in the Value Modifier  program.
Agency officials said that CMS expects to apply its Value Modifier  annually 1 year after the performance period ends. The agency has chosen to provide performance feedback reports 9 months after the end  of the performance year, about 3 months before it would be applicable to  the Value Modifier. For example, CMS would disseminate physician  group feedback reports in the fall of 2014 that contain 2013 performance  data to physician groups subject to the Value Modifier, and these reports  will be the basis for the Value Modifier starting in 2015. According to  agency officials, the interval between the performance period and the  initial feedback reports is needed to capture a lag in data submissions (up  to 3 months after the end of the year), adjust claims for price  standardization and risk, and conduct quality assurance testing. However,  CMS may have a sufficient amount of reliable performance data with  which to make more timely incentive payments in the Value Modifier  program. The Research Data Assistance Center—a CMS contractor that  provides technical support on Medicare claims processing—states that  claims data are generally complete 6 months from the end of the calendar  year. For example, over 96 percent of Medicare claims from 2011 were  finalized by July of 2012.
section_title: CMS’s Efforts Have Increasingly Focused on Promoting Care Coordination
paragraphs: CMS supports care-coordination incentives through several approaches.  For 2013, CMS designated three additional care-coordination metrics in  its administrative-based claims reporting for the group Value Modifier. For  example, because care-coordination programs may reduce hospital  readmissions, CMS plans to measure the rate of hospital readmissions  within 30 days after being discharged. In addition, to encourage patient  follow-up postdischarge, CMS has developed a set of physician billing  codes for services delivered within 30 days of discharge from a hospital  or skilled nursing facility. Finally, CMS pays a monthly care-management  fee to selected primary care practices under both its Comprehensive  Primary Care Initiative and Multi-Payer Advanced Primary Care Practice  Demonstration for purposes such as coordinating care for high-risk  beneficiaries and helping to engage them in their care.
section_title: CMS Plans to Publicly Report Physician Groups’ Performance Metrics on Its Physician Compare Website
paragraphs: In addition to regularly providing performance feedback to physicians,  CMS intends to report physician performance scores to the public. As  required by PPACA, CMS has implemented a plan for publicly reporting  physician quality and patient experience metrics through the Physician  Compare website. CMS developed Physician Compare to make  information on quality of care widely available so that beneficiaries can  make informed decisions in their choice of physician, and to encourage  physicians to improve their quality of care. Agency officials said that CMS  will begin publicly reporting statistically reliable performance results of  physician groups submitted through the PQRS Group Practice Reporting  Option in 2013 or early 2014.
section_title: Conclusion
paragraphs: Many of the themes we identified among private entities implementing  payment incentives are generally accepted by physician organizations in  our study and are reflected—in whole or in part—in CMS’s efforts to  implement the Value Modifier program. CMS has recognized the  importance of group-level measurement, particularly through its initial  application of the Value Modifier exclusively to physician groups.  According to CMS officials, the agency has also begun to standardize its  metrics across its programs while generally adhering to nationally  accepted measures that are endorsed by entities such as NQF. Finally,  CMS has taken steps to provide incentives for greater care coordination  through both additional payments and performance metrics.
While CMS has taken steps toward addressing measurement of large  physician groups, PPACA requires that the Value Modifier apply to all  physicians—including those in solo and small practices—in 2017. To  meet this requirement, CMS must address concerns regarding how best  to reliably measure performance at that level. The challenge of measuring  the performance of physicians in solo and small practices is more  significant for CMS than for private entities because Medicare provides  payment to any willing provider of care for beneficiaries. Yet, CMS has  not laid out a strategy for its eventual application of the Value Modifier to  solo and small-practice physicians in a manner that ensures  measurement credibility. Options for doing so could include aggregation  of solo and small practices into informal groups for measurement  purposes.
Despite similarities to some themes found among private entities with  physician payment initiatives, other themes are not fully reflected in  CMS’s Value Modifier program. For instance, most of the private entities  in our study provide incentives that are tied to absolute performance  benchmarks or some combination of absolute benchmarks and improved  performance; in addition to approving the use of absolute benchmarks,  physicians in our review favored incentives that reward improvement  because baseline levels of performance vary. Until CMS provides  incentives for improvement, it is likely that few physician groups that are  not already high performers will opt to participate in its quality-tiering  approach.
Additionally, because CMS’s Value Modifier adjusts payments to  physicians a year after the end of the performance period, the motivation  to improve performance is diluted. While CMS has noted the need for   1 year to ensure accurate data, most of the private entities we contacted  make incentive payments within 7 months of the end of the performance  period so that physicians can readily see the financial effect of their  performance. CMS’s 1-year time lag between performance measurement  and payment adjustment may diminish the significance of the incentive to  physicians.
section_title: Recommendations for Executive Action
paragraphs: As CMS continues to implement and refine the Value Modifier program to  enhance the quality and efficiency of physician care, the Administrator of  CMS should consider whether certain private-sector practices could  broaden and strengthen the program’s incentives. Specifically, she should  consider developing at least some performance benchmarks that reward  physicians for improvement as well as for meeting absolute  performance benchmarks, and making Value Modifier adjustments more timely in order to better  reflect recent physician performance.
The Administrator should also develop a strategy to reliably measure the  performance of solo and small physician practices, such as by  aggregating their performance data to create informal practice groups.
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 I, the department concurred with all  three recommendations. Specifically, HHS stated that  it will consider developing performance benchmarks that reward  physician improvement once the agency has greater physician  reporting on quality measures; as it develops the technology to handle claims data and quality data  more rapidly, it will look for ways to decrease the gap between the  performance period and the application of the Value Modifier; and it will seek to develop strategies to reliably measure the  performance of solo and small physician practices.
HHS 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 staff 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 II.
section_title: Appendix I: Comments from the Department of Health and Human Services
section_title: Appendix II: 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;  David Grossman; Kate Nast; and Luis Serna III.