- Email: [email protected]
Medicare Quality and Resource Use Reports: Crunching Data or Crushing Data
WASHINGTON WATCH
MICHAEL J. PENTECOST, MD
Medicare Quality and Resource Use Reports: Crunching Data or Crushing Data Unsurprisingly, physicians keep a pretty close eye on Medicare payment policy, and most are very familiar with sustainable growth rate formulas, relative value schedules, 5-year reviews, and the like [1]. Many don’t know—at least until recently—much about some arcanesounding tools, such as Medicare payment modifiers and resource use reports. But that will change, and soon, with the introduction in 2012 by CMS of a new reimbursement instrument that, by 2017, will affect nearly all physicians. This mechanism, mellifluously titled Physician Value-Based Payment Modifiers and also termed Medicare Quality and Resource Use Reports, is part of a broad movement in health care called value-based purchasing [2]. That term is defined as any purchasing practices aimed at improving the value of health care services, where value is a function of both quality and cost (value ⫽ quality/cost). The modifiers are different from the now well-known pay-for-performance strategies, in that they are intended to encourage quality and cost as opposed to just quality. Among the more than 40 metrics used as quality components in the modifiers, examples include the following, based on claims or Physician Quality Reporting System measures: ●
Pharmacotherapeutic management of chronic obstructive pulmonary disease exacerbation X Dispensed corticosteroids or bronchodilators
●
Prostate-specific antigen monitoring for men with prostate cancer
●
● ●
●
●
Dilated eye examinations for beneficiaries ⱖ75 years of age with diabetes Persistence of -blocker treatment after heart attack Anticoagulation treatment ⱖ3 months after deep vein thrombosis or pulmonary embolism Prescriptions for nonsteroidal anti-inflammatory drugs for patients with chronic renal failure Pneumonia vaccination for patients ⱖ65 years of age
Most physicians are at least partly familiar with these clinical quality metrics. But the cost data is a different story, and the definitions, rules, and outcomes are something entirely new. The CMS divides costs into 3 categories: Directed care costs are for patients for whom individual physicians bill 35% or more of outpatient evaluation and management visits. Influenced care is when a physician bills less than 35% of evaluation and management care but more than 20% of total professional costs. Such cases might involve care by a surgeon or interventionalist. Contributed care covers instances when a physician bills less than 35% of evaluation and management visits and less than 20% of total professional costs. Four disease states will be the subject of the cost analysis: diabetes, coronary artery disease, chronic obstructive pulmonary disease, and heart failure. One of the goals of health care reform was to supercharge innovation and the impact of quality and cost initiatives. It is not hard to see that resource use reports are a middle ground (or safety net) on
© 2012 American College of Radiology 0091-2182/12/$36.00 ● http://dx.doi.org/10.1016/j.jacr.2012.05.009
the way toward accountable care organizations, with their more formal partnerships, fixed terms, bundled payments, tighter structure, and larger patient populations. In April 2012, the first to get a glance at their data (for performance in 2010) were the 20,000 physicians practicing in four midwestern states: Iowa, Kansas, Missouri, and Nebraska (Figure 1). For other providers, the program will start in 2015 and include nearly all physicians by 2017. The scope of the financial rewards remains unspecified, and although bonuses won’t be paid until 2015, they will be determined by 2013 performance, just 5 months away. The publicity surrounding the release of these data focused attention on several problems with this approach [3]. First, until now, most measures have concentrated on hospitals with much greater volumes than an individual physician practice, some of which may have small, or even very small, numbers, thereby making statistical analysis unfeasible. Also, an individual Medicare patient can not uncommonly have a dozen physicians, and one outlier in quality or cost can taint the entire group. The modifiers may be a step up the sustainable growth rate formula in which all physicians pay for the conduct of a few. But inaccurate attribution of care may fatally undermine the program. Last, risk adjustment, no small task in Medicare patients, must be comprehensive enough to evenhandedly recognize physicians and at the same time avoid selection bias against sicker beneficiaries. 539
540 Washington Watch
Fig 1. Distribution in 2010 total per capita costs of physician directed, influenced, and contributed care: illustrative example [2].
The great unknowns about resource use reports are their effectiveness and fairness. To change behavior, they must have an impact, thereby exposing physicians to significant financial risk; to be a durable instrument of change, they must be applied equitably or
risk being unwound by a groundswell of opposition. REFERENCES 1. Ginsburg PB. Rapidly evolving physicianpayment policy: more than the SGR. N Engl J Med 2011;364:172-6.
2. Centers for Medicare and Medicaid Services. 2010 Quality and Resource Use Report, Medicare fee-for-service. Available at: http:// www.cms.gov/Medicare/Medicare-Fee-forService-Payment/PhysicianFeedbackProgram/ downloads/2010_individual_qrur_template. pdf. Accessed April 16, 2012. 3. Rau J. Medicare moves to tie doctors’ pay to quality and cost of care. The Washington Post. April 15, 2012:A2.
Michael J. Pentecost, MD, Magellan Health, 6950 Columbia Gateway Drive, Columbia, MD 21046; e-mail: [email protected].
MICHAEL J. PENTECOST, MD
Medicare Quality and Resource Use Reports: Crunching Data or Crushing Data Unsurprisingly, physicians keep a pretty close eye on Medicare payment policy, and most are very familiar with sustainable growth rate formulas, relative value schedules, 5-year reviews, and the like [1]. Many don’t know—at least until recently—much about some arcanesounding tools, such as Medicare payment modifiers and resource use reports. But that will change, and soon, with the introduction in 2012 by CMS of a new reimbursement instrument that, by 2017, will affect nearly all physicians. This mechanism, mellifluously titled Physician Value-Based Payment Modifiers and also termed Medicare Quality and Resource Use Reports, is part of a broad movement in health care called value-based purchasing [2]. That term is defined as any purchasing practices aimed at improving the value of health care services, where value is a function of both quality and cost (value ⫽ quality/cost). The modifiers are different from the now well-known pay-for-performance strategies, in that they are intended to encourage quality and cost as opposed to just quality. Among the more than 40 metrics used as quality components in the modifiers, examples include the following, based on claims or Physician Quality Reporting System measures: ●
Pharmacotherapeutic management of chronic obstructive pulmonary disease exacerbation X Dispensed corticosteroids or bronchodilators
●
Prostate-specific antigen monitoring for men with prostate cancer
●
● ●
●
●
Dilated eye examinations for beneficiaries ⱖ75 years of age with diabetes Persistence of -blocker treatment after heart attack Anticoagulation treatment ⱖ3 months after deep vein thrombosis or pulmonary embolism Prescriptions for nonsteroidal anti-inflammatory drugs for patients with chronic renal failure Pneumonia vaccination for patients ⱖ65 years of age
Most physicians are at least partly familiar with these clinical quality metrics. But the cost data is a different story, and the definitions, rules, and outcomes are something entirely new. The CMS divides costs into 3 categories: Directed care costs are for patients for whom individual physicians bill 35% or more of outpatient evaluation and management visits. Influenced care is when a physician bills less than 35% of evaluation and management care but more than 20% of total professional costs. Such cases might involve care by a surgeon or interventionalist. Contributed care covers instances when a physician bills less than 35% of evaluation and management visits and less than 20% of total professional costs. Four disease states will be the subject of the cost analysis: diabetes, coronary artery disease, chronic obstructive pulmonary disease, and heart failure. One of the goals of health care reform was to supercharge innovation and the impact of quality and cost initiatives. It is not hard to see that resource use reports are a middle ground (or safety net) on
© 2012 American College of Radiology 0091-2182/12/$36.00 ● http://dx.doi.org/10.1016/j.jacr.2012.05.009
the way toward accountable care organizations, with their more formal partnerships, fixed terms, bundled payments, tighter structure, and larger patient populations. In April 2012, the first to get a glance at their data (for performance in 2010) were the 20,000 physicians practicing in four midwestern states: Iowa, Kansas, Missouri, and Nebraska (Figure 1). For other providers, the program will start in 2015 and include nearly all physicians by 2017. The scope of the financial rewards remains unspecified, and although bonuses won’t be paid until 2015, they will be determined by 2013 performance, just 5 months away. The publicity surrounding the release of these data focused attention on several problems with this approach [3]. First, until now, most measures have concentrated on hospitals with much greater volumes than an individual physician practice, some of which may have small, or even very small, numbers, thereby making statistical analysis unfeasible. Also, an individual Medicare patient can not uncommonly have a dozen physicians, and one outlier in quality or cost can taint the entire group. The modifiers may be a step up the sustainable growth rate formula in which all physicians pay for the conduct of a few. But inaccurate attribution of care may fatally undermine the program. Last, risk adjustment, no small task in Medicare patients, must be comprehensive enough to evenhandedly recognize physicians and at the same time avoid selection bias against sicker beneficiaries. 539
540 Washington Watch
Fig 1. Distribution in 2010 total per capita costs of physician directed, influenced, and contributed care: illustrative example [2].
The great unknowns about resource use reports are their effectiveness and fairness. To change behavior, they must have an impact, thereby exposing physicians to significant financial risk; to be a durable instrument of change, they must be applied equitably or
risk being unwound by a groundswell of opposition. REFERENCES 1. Ginsburg PB. Rapidly evolving physicianpayment policy: more than the SGR. N Engl J Med 2011;364:172-6.
2. Centers for Medicare and Medicaid Services. 2010 Quality and Resource Use Report, Medicare fee-for-service. Available at: http:// www.cms.gov/Medicare/Medicare-Fee-forService-Payment/PhysicianFeedbackProgram/ downloads/2010_individual_qrur_template. pdf. Accessed April 16, 2012. 3. Rau J. Medicare moves to tie doctors’ pay to quality and cost of care. The Washington Post. April 15, 2012:A2.
Michael J. Pentecost, MD, Magellan Health, 6950 Columbia Gateway Drive, Columbia, MD 21046; e-mail: [email protected].