Technical Assistance Required
By Amy Lynn Sorrel Texas Medicine July 2015

New Medicare Quality Reports Give Physicians Critical Feedback, But Make It Difficult to Interpret

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Quality Feature — July 2015

Tex Med. 2015;111(7):59-62.

By Amy Lynn Sorrel
Associate Editor

The new quality feedback reports Medicare released last fall finally give all physicians actionable data to gauge their performance in the various federal quality reporting mandates and to measure the impact of the programs on their practices in a fast-approaching value-based care system. 

But doctors say they should come with a warning label: "Technical Assistance Required." 

The Quality and Resource Use Reports (QRURs) provide detailed information on physicians' quality and cost performance and how they compare with their peers. Because those scores feed directly into how Medicare now calculates payment penalties under the value-based payment modifier — and eventually will determine financial bonuses and penalties under the new Merit-Based Incentive Payment System (MIPS) — the information is critical, says Texas Medical Association Council on Health Care Quality member Michael Ragain, MD. 

The family physician and chief medical officer at University Medical Center Health System in Lubbock saw from his group's report that the doctors faced a potential penalty this year, and they were able to make adjustments in time to avoid it. 

"It's really the first time we actually had that kind of clinical data feedback," Dr. Ragain said.

But to unravel the mystery of scattergrams and composite scores, he had to get help from TMF Health Quality Institute, the Medicare-contracted statewide quality improvement organization and network. 

"Medicare is moving this direction [toward value-based care] like a freight train. But even for a large group practice like ours, it's very complex. It's very confusing. And it's very overwhelming," Dr. Ragain said. "Simplification would be greatly appreciated."

Paradigm Shift

At medicine's urging, the Centers for Medicare & Medicaid Services (CMS) began releasing the confidential QRURs to all Medicare physicians treating fee-for-service patients. Previously, they were available only to large groups because they were the first ones subject to the value modifier. CMS' initial wide-scale distribution of QRURs in September 2014 contains 2013 quality and cost data, and Medicare plans to release the reports at least annually, each fall, with data from the prior year.

The QRURs may add another enigmatic acronym to the alphabet soup of quality reporting mandates to which physicians are now held. (See "Your Guide to Medicare Value-Based Care," April 2014 Texas Medicine, pages 26-34.) But the information is especially important, as the work physicians do now determines bonuses or penalties in their payments two years down the line.

The release coincides with Medicare's implementation of the value modifier, which adjusts physician payments based on the quality data they report to the Physician Quality Reporting System (PQRS) and on Medicare cost data, all from two years prior. Payments to large practices face adjustments this year based on 2013 quality and cost data. The 2015 data will determine payments for all physicians in 2017 and beyond. (See "Value-Based Payment Modifier Takes Effect.") 

TMA officials say the QRURs also help set expectations for what's to come under MIPS, which Congress created when it eliminated the Medicare Sustainable Growth Rate (SGR) formula in April under the Medicare and CHIP Reauthorization Act of 2015. (See "R.I.P. SGR," June 2014 Texas Medicine, pages 26-37.) Under the new payment paradigm, Medicare's three main quality reporting programs — PQRS, the value modifier, and meaningful use of electronic health records (EHRs) — remain in effect through 2018. Starting in 2019, MIPS will combine them into a single value-based program that continues to assess physician performance and payment based on quality, utilization, clinical practice improvement activities, and EHR use. 

Critical Feedback

"The QRURs give physicians a window into their current performance and how they may fare in the future," says Tracy Swoboda. She oversees value-based payment initiatives as project director for TMF's most recent contract as the state's quality improvement organization. "The purpose of the methodology is to help physicians understand their performance and identify practice opportunities for improvement," she said.

The reports give information on:  

  • PQRS quality measures submitted via claims, registry, or EHRs; 
  • Other claims-based quality measures CMS uses for the value modifier; and 
  • Medicare cost measures, such as hospital admissions or condition-specific costs.   

The QRUR scattergram depicts an overview of how physicians compare with their peers and whether they fall above, below, or within average in terms of cost and quality. 

An overall quality score reflects physician performance in measures derived from as many as six quality categories — called domains — established under CMS' National Quality Strategy:   

  • Clinical process/effectiveness,
  • Patient and family engagement, 
  • Population/public health, 
  • Patient safety,
  • Care coordination, and
  • Efficient use of resources.  

Not all physicians will have scores for all domains, depending on which measures they choose to report.

An overall cost score summarizes how practices fare on utilization across two cost categories, or domains: per-capita costs for all attributed Medicare patients and per-capita costs for patients with specific chronic conditions — diabetes, coronary artery disease, chronic obstructive pulmonary disease, and heart failure. 

Ms. Swoboda acknowledges the tables and calculations can be daunting, which is why TMF offers the QRUR Interpretation and Quality Improvement Guide to help physicians not only interpret the findings but also act on them. Physicians also can join TMF's online Value-Based Improvement and Outcomes Network to get no-cost technical assistance with Medicare's various quality reporting programs. (See "QRUR Resources.")

From the data, Dr. Ragain saw his group was approaching penalty territory based on negative scores in quality measures that discourage use of certain medications in the elderly. But that also meant he could pinpoint specific areas to enhance care delivery.

"There are all kinds of rationales we use to not do what's recommended: Somebody may be on a drug for a while when they are not geriatric, but then they age into the group. Or the meds are working, so why mess with them? And it's possible it's right not to do what's recommended. But generally speaking, we know we have too many disease effects, and it leads to problems," Dr. Ragain said. Once the group identified the gaps in care, "it was relatively easy to put a system in place around those metrics, and we were able to move out of the penalty box without a lot of focused work. Just like anything, if you set up a system to deliver that care, it works better than depending on individual memory."

Help, Please  

As with many Medicare programs, however, the QRURs are "a step in the right direction, but [CMS] made it harder than it should be," Dr. Ragain added.

The reports can be 20 pages long; CMS' instructions can range up to 100 pages. 

Dr. Ragain also notes the QRURs only show aggregate patient data, and physicians have to download and sift through separate Excel spreadsheets to drill down into how Medicare calculates their cost and quality scores. Even then, the information is at least a year old, "so you're looking at your wake, not what's in front of you."

And the quality data are easier to interpret than the cost data, he adds. "That's information we don't have access to in our practice. We're just rolled in [with other entities] and held accountable for things we don't manage," making it difficult for practices to understand which costs they are responsible for — versus hospitals or other practices, for example — let alone make adjustments to improve.

As elusive is the process for accessing the QRURs in the first place. 

A Harris County Medical Society (HCMS) study revealed significant inefficiencies and redundancies in the CMS portals physicians must use to submit and retrieve their quality data. 

Under one gatekeeping system, for example, physician groups must register and create an account and password to submit their information to PQRS. The process can take 30 days, often requiring Internal Revenue Service documents. An entirely separate system exists for meaningful use reporting and Medicare enrollment. Delegating reporting tasks to staff requires lengthy registration processes. 

To retrieve a QRUR, physicians must revalidate their security access in PQRS to get into a separate portal housing the reports. Doctors must follow a similar process to get their PQRS feedback reports, which sit in a separate portal. 

Four HCMS physicians could not successfully report to PQRS in 2014 simply because they were unable to register on time. 

Houston neurologist and past HCMS President William S. Gilmer, MD, says demonstrating quality of care is complicated enough without added layers just to put data in and get data out. The solo physician and his staff spent 20 hours combing through 100-page CMS documents and calling helpdesks to figure out how to submit PQRS data via his EHR system. 

"I think I successfully submitted, but I still don't know because CMS won't tell me until fall of this year," Dr. Gilmer said. He anticipates his QRUR will provide valuable insight into how his practice is faring, but he is not looking forward to slogging through the technicalities to find out.

"It's available to me. But the Medicare rules and the tax code are available to me, also, and it takes legions of accountants and lawyers to understand those," Dr. Gilmer said. "We all want quality, and I want to know if I'm in the ballpark and if I'm doing the right thing. But CMS makes it impossible for me to find out." 

Bright Spots Ahead

Organized medicine, including TMA, continues to advocate that Medicare streamline its quality reporting requirements and eliminate unwarranted penalties, while giving physicians timely feedback on their performance. 

In a Jan. 30 letter to CMS, the Medical Group Management Association (MGMA) urges federal officials to start by using "one portal for physicians and practices to report and access all information pertaining to Medicare Part B programs. … It makes no practical sense to have multiple systems which create unnecessary work." 

At press time in mid-May, CMS announced that starting July 13, it planned to transition from the cumbersome system for PQRS users to a single portal for submitting data, retrieving and viewing feedback reports, and other administrative and maintenance activities. 

Thanks to medicine's ongoing advocacy, bright spots will appear with the sunset of the SGR formula. 

The consolidated MIPS quality reporting program that begins in 2019 will include clearer targets for improvement and prompter feedback on physician performance. Instead of waiting to hear back from CMS, physicians will know the threshold score for successful performance at the start of each performance period, and Medicare will issue quarterly QRURs. Doctors also will have more chances to get financial bonuses for their quality improvement activities, instead of just facing penalties. 

Information on how many physicians currently access the QRURs is not readily available. MGMA suggests the answer is "not enough": The association's letter points out that just 26,000 out of 546,000 physicians — a mere 5 percent — registered in CMS' new Open Payments system to review the payments attributed to them when it launched last September.

PQRS participation in Texas, however, is on the rise, suggesting physicians are doing their part. (See "PQRS Participation on the Rise in Texas.")

Dr. Gilmer says for that to continue, especially now that the incentive payments for participation in CMS quality initiatives have shifted entirely to penalties, CMS must do its part. "If the goal is to get physicians to submit their quality data and participate in quality improvement, they need to start with the doctor in mind." 

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

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QRUR Resources

TMF Health Quality Institute: QRUR Interpretation and Quality Improvement Guide
TMF: Value-Based Improvement and Outcomes Network
Centers for Medicare & Medicaid Services (CMS): How to Obtain a QRUR 
CMS: Value-Based Payment Modifier fact sheets

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Last Updated On

May 25, 2016

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