Out in the Open

Medicare Publishes Quality Data

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Quality Feature — June 2014

Tex Med. 2014;110(6):29-32.

By Amy Lynn Sorrel
Associate Editor

When Temple family physician Tiffany Berry, MD, looked up her name in Medicare's Physician Compare, she easily found her profile publicly displayed on the website meant to help patients search for information on Medicare physicians. Listed are her specialty and location, whether she takes Medicare patients, and her participation in federal quality initiatives like the Physician Quality Reporting System (PQRS). 

However, to look up the new quality data Medicare recently published for her and other large groups, Dr. Berry had to search the name of her practice, Scott & White Clinic, on the Physician Compare website.  

"I'm not sure that's the way patients think" when they want to find their doctor or switch to a new one, said Dr. Berry, chief quality officer at Baylor Scott & White Health Central Texas Division. Nor is she confident patients will understand the stars and percentage scores, which represent Scott & White's performance on quality measures, such as controlling blood sugar levels and blood pressure in patients with diabetes, that now adorn her practice's name. 

"We are assuming patients are going to go to the website. We're assuming they can figure out how to navigate it. We're assuming patients are going to use this to inform their decision. And we're assuming they are going to understand and find value in the five metrics they are going to see. That's a lot of assumptions," she said.

In February, Medicare for the first time added the quality data to Physician Compare with the goal of helping patients make informed health care choices. The addition comes at a time of heightened interest in transparency, and this year the website includes quality information for certain large group practices and accountable care organizations (ACOs). The Centers for Medicare & Medicaid Services (CMS) plans to phase in more measures and make quality data public for all Medicare physicians in the coming years.

The Texas Medical Association and physicians like Dr. Berry generally support transparency to help improve patients' quality of care. But TMA and the American Medical Association continue to advocate for safeguards that ensure any physician data published to that end are useful and accurate. That could prove more important as patients increasingly use rating sites like Physician Compare to choose their doctors. In a University of Michigan Medical School survey published in the February 2014 issue of the Journal of the American Medical Association (JAMA), 59 percent of respondents found online physician rating sites to be "somewhat important" or "very important" when choosing a physician, but they still relied more heavily on other factors like word of mouth from family and friends. 

The good news, says TMA Council on Health Care Quality member Ronald S. Walters, MD, is physicians have some control over the quality data published because they are the ones reporting it directly to CMS. The bad news, says the Houston oncologist, is Physician Compare remains error-ridden, "and that has to be worked out, or there's going to be no trust behind the quality data that are being added." 

Quality Data Go Public

CMS did not respond to Texas Medicine interview requests. In a February press statement, CMS Chief Medical Officer and Deputy Administrator for Innovation and Quality Patrick Conway, MD, said, "Offering a strong set of meaningful quality measures on the site will ultimately help consumers make decisions, and it will encourage quality improvement among the clinician community, who shares CMS's strong commitment to the best possible patient care."

Physician Compare, created by the 2010 Affordable Care Act, already included basic demographic information on Medicare physicians, including names, addresses, board certification, and group practice and hospital affiliations. The public website also noted physicians' participation in three federal quality improvement programs: PQRS and the electronic prescribing (eRx) and electronic health record (EHR) incentive programs.

CMS redesigned the website in 2013 in anticipation of posting the first set of physician quality data this year. The five quality measures added for large groups and ACOs include: 

  • Controlling blood sugar levels in patients with diabetes,
  • Controlling blood pressure in patients with diabetes,
  • Prescribing aspirin to patients with diabetes and heart disease,
  • Screening diabetic patients for tobacco use, and
  • Prescribing medicine to improve the pumping action of the heart in patients who have both heart disease and certain other conditions. 

Physician Compare lists each measure separately, along with information to help patients understand it. The site displays scores for how well the group performed on each measure as a percentage and a corresponding five-star scale. For example, each star represents 20-percent compliance, so if a group scored 84 percent on a measure, patients would see four stars and part of a fifth. 

For now, the data apply only to ACOs and group practices of 100 or more physicians. CMS initially anticipated including quality data for all individual physicians by 2017 but has not yet specified any dates. 

The new quality scores released come from the 2012 quality data that physician groups and ACOs reported to CMS through the PQRS, eRx, and EHR programs. TMA officials add that if CMS sticks to its 2017 target for publicizing individual physician quality scores, for example, that information would be based on 2015 reporting.

That means physicians aren't helpless when it comes to the information Physician Compare presents to patients, Dr. Walters says. He acknowledges the quality reporting process can be costly and time-consuming, especially for smaller practices. 

Still, "if you are concerned about the quality of the information being out there in the public forum in future versions of Physician Compare, you are completely in control of that quality because you provide the data," he said. 

Dr. Walters adds physicians' specialty societies, not CMS, largely develop the quality measures physicians report and patients ultimately see. (See "Measure of Success," April 2013 Texas Medicine, pages 59-63.) 

On the other hand, he says Medicare's track record with Physician Compare is less than perfect. Dr. Walters was among a number of physicians who found inaccuracies in his demographic profile in the first version of Physician Compare. He works at MD Anderson Cancer Center, but the website listed him with another hospital in town. 

TMA's Payment Advocacy Department has fielded similar complaints about mismatched data. Officials say such mistakes occur mostly because Medicare does not regularly update the Provider Enrollment, Chain and Ownership System (PECOS) it uses to update Physician Compare. The department recommends physicians carefully and regularly monitor their profiles to catch any errors. 

The faults are just one reason organized medicine has urged CMS to hold off on expanding Physician Compare with performance data. "Furthermore, it undermines physicians' trust in CMS' ability to expand and correctly post their quality scores on Physician Compare," AMA Executive Vice President and Chief Executive Officer James L. Madera, MD, told federal officials in a March letter. 

CMS gave group practices 30 days to preview their quality measures before publicly reporting them, and the agency says it will correct any errors. But there is no formal appeal process. 

Already, physicians often wait months to see the changes they make in PECOS show up on Physician Compare, the AMA letter states. In addition, "the AMA, medical specialty societies, and state medical societies received no advance notice regarding the posting of this [quality] information. Consequently, we were unable to notify the physician community that this new rating system was coming. Nor were we provided an opportunity to review the information in advance of its posting."

Organized medicine's letter calls on CMS to give physicians additional time and opportunities to correct their information before posting it on the website, particularly for practices that don't have or can't afford robust quality measurement or EHR systems. 

TMA Council on Health Care Quality member Ghassan Salman, MD, adds that faulty information, particularly when it comes to quality, could pose unintended harm to patients' health and to physicians' livelihood. The Austin internist was TMA's 2008-12 representative to the AMA Physician Consortium for Performance Improvement. 

"The last thing we want to do is send out wrong information about anybody. This information is very specific about the health care of the patient, and it impacts the physician's reputation," he said. "We have to make sure the information is correct. And we have to make sure it is shared with the physician or the practice before being published." 

According to the JAMA study, 35 percent of patients who sought online physician ratings selected a physician based on good scores; 37 percent avoided physicians with bad scores.

Lost in Translation

Fortunately for Scott & White, Dr. Berry and her staff found no errors during the review process. 

"It is nice that we are the people reporting our own data," she said, adding that the stars are relatively easy for physicians to figure out. 

That may not be the case for patients, however. Dr. Berry described a number of nuances to quality reporting that can get lost in translation when CMS transforms the information into the ratings patients ultimately see on Physician Compare. 

For one, to satisfy certain quality measures, physicians must do a lot more documentation, which doesn't necessarily reflect the quality of care they give their patients, Dr. Berry says. "It's 50 percent doing the right thing for the patient and 50 percent knowing rules of the game on how to report. We are here to do the right thing for the patient."

For example, if Dr. Berry treats a diabetic patient but doesn't document whether the patient takes aspirin because she's not prescribing it, "that is considered a failure" on that particular quality measure, she says. "Also, the data is old. It's from 2012, and we can change a lot in a year."

TMA Director of Clinical Advocacy Angelica Ybarra, RN, adds that for some specialties, there are insufficient applicable quality measures to report on in the first place, which could unfairly skew the rankings. 

Because of these and other shortfalls of quality measurement, "it is critical that the development of a plan for public reporting of physician performance through Physician Compare recognize these factors, and for CMS to continue to implement initiatives on a phased-in basis," AMA's letter cautions. 

And once the quality information is out, physicians question how useful it is to patients.

CMS says stars are consumer-friendly and familiar, and it added the percentage scores "for full transparency" and to further help patients understand the quality information. 

Dr. Walters recognizes CMS must find a way to easily communicate the quality information in a way patients understand it but says oversimplifying the results could instead confuse or mislead patients. For example, three versus four stars next to a group practice's name or an 80-percent versus a 90-percent ranking of how well the practice complied with a particular measure may not clearly reflect the fact that the care given in both instances is still good care and not dramatically different.

Ms. Ybarra says Physician Compare, coupled with a growing number of commercial health plan ranking programs, adds to the confusion for patients who see physicians with different ratings on the different sites. That's why TMA continues to advocate for consistency across the various programs. 

Dr. Berry says what patients really want to know is, "Are [the doctors] going to treat me with respect? Are they going to listen? Are they going to follow up with me? And is my care going to be coordinated? That's much more valuable to patients than what percentage of my diabetes patients use tobacco."

CMS recently began collecting such patient experience data from practices through the Consumer Assessment of Healthcare Providers and Systems survey. Such reporting is optional for now but could become mandatory in the future. (See "Survey Says …," March 2014 Texas Medicine, pages 49-53.) 

Dr. Berry says patients "should have the opportunity to make informed decisions, and [Physician Compare] is a step toward that. But we have a long way to go."

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

June 2014 Texas Medicine Contents
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