When it comes to objective measures of quality, efficiency, and outcomes, the public has not had access to reliable data on which to base health-care provider decisions-- until now. Physicians Compare, launched in 2010, is a valuable resource of all Medicare-participating physician and health-care professionals' basic demographical information, education, board certification, whether the provider has attested to Meaningful Use and participated in the PQRS and more.
Our decisions to buy a certain product or service are often based on opinions expressed by prior purchasers. In addition to soliciting advice from friends and family, we have at our fingertips hundreds of Web sites by which to access others’ opinions (and express our own opinions as well).
While other users’ subjective opinions can be helpful, knowing a product’s or service’s score on objective measures gives us greater confidence in our purchasing decisions. Thus, we rely on publications like Consumer Reports and look for designations such as the Good Housekeeping Seal. In selecting a health-care provider, we first check our insurance coverage and then ask our primary-care provider (if we have one), inquire about our friends’ and family members’ experiences, and surf Web sites like HealthGrades and Vitals, to name just two. But when it comes to objective measures of quality, efficiency, and outcomes, the public has not had access to reliable data on which to base decisions—until now.
INTRODUCING PHYSICIAN COMPARE
Section 10331 of the Affordable Care Act (ACA) required the Centers for Medicare & Medicaid Services (CMS) to establish the Physician Compare Web site to provide consumers with objective measures of physician performance. When it was launched on December 30, 2010, Physician Compare was nothing more than a searchable list of physicians and other health-care professionals who bill for services on the Medicare Physician Fee Schedule (MPFS). Over the last five years, CMS has expanded the information available on the site and enhanced its functionality.
Today, Physician Compare makes available the following information for every Medicare-participating physician and health-care professional:
- Basic demographic information
- Medical school education and residency information
- Primary and secondary specialty
- Board certification (if any)
- Practice and hospital affiliations
- Languages spoken
- Whether the provider has attested to Meaningful Use and participated in the Physician Quality Reporting System (PQRS) and the Million Hearts® initiative in the most recent year.
In addition to finding a physician who is part of group practice, one can also access a complete list of other physicians in the group by specialty. A consumer can use Physician Compare to obtain information on his or her current physician using an individual or group name search.One can also search for a provider within a specified radius of a city, zip code, or landmark, segregated by specialty.The site includes a tool that allows the user to click on different areas of the body to identify the specialty he or she is seeking.
EXPANDING PHYSICIAN COMPARE
The ACA required CMS to publish a plan by the end of 2013 to expand Physician Compare to include individual providers’ data on cost and quality measures. With that plan in place, CMS is now methodically expanding the site’s functionality.
In December 2014, CMS posted the first set of quality measures on Physician Compare: They were diabetes and coronary artery disease measures. These were collected for 139 group practices and 237 accountable care orgranizations (ACOs) via the Web interface for the 2013 PQRS Group Practice Reporting Option (GPRO).
Late last year, CMS added individual providers’ quality data for the first time, posting to Physician Compare a subset of 2014 PQRS measures collected via claims data, along with individual provider measures from the 2014 PQRS cardiovascular prevention measures group in support of the Million Hearts® initiative. Also in 2015, CMS added to Physician Compare a subset of the 2014 PQRS GPRO measures collected via the Web interface for group practices of 25 or more eligible professionals, along with certain patient satisfaction scores reported by these practices.
CMS will continue to grow the amount of data available through Physician Compare, but only for those measures the agency deems statistically valid, reliable, and suitable for public reporting. CMS conducts consumer testing to identify the most appropriate measures to post on Physician Compare. This includes having consumers evaluate the plain-language measure descriptions and discussing with consumers how and if the measure would help them choose a physician.
Once CMS deems a measure appropriate for reporting, the agency then makes a formal proposal for posting on Physician Compare through the annual MPFS rulemaking process. Stakeholders can then seek clarification and raise objections regarding the measure and/ or the manner in which CMS proposes to report the data on the Web site.
And, as one final check before any quality data is posted on Physician Compare, there is a 30-day preview period, during which a group practice or individual provider can review the data and raise any objections or concerns regarding its accuracy or the manner in which it will be reported. CMS also posts on Physician Compare disclaimers warning consumers that a physician’s scores on quality measures do not necessarily reflect his or her skills and abilities.
MIPS AND PHYSICIAN COMPARE
Medicare’s current physician valuebased purchasing programs, including PQRS, will be phased out over the next three years and replaced with the Merit- Based Incentive Payment System, or MIPS. Beginning on January 1, 2019, all MPFS payments will be subject to upward or downward adjustments, based on an individual physician’s MIPS composite score.
That composite score—expressed as a number between 1 and 100—will be calculated using a physician’s score on specified quality measures:
- 30% of the composite score
- Efficiency measures (30%)
- Meaningful use of an electronic health record (25%)
- Reported clinical practice improvement activities (15%)
On an annual basis, CMS will calculate a national performance threshold. Physicians scoring above that number will see upward adjustments to their fee schedule payments, while those with lower scores will be penalized.
The legislation creating the MIPS program, the Medicare Access and CHIP Reauthorization Act (MACRA), requires that each physician’s MIPS composite score be posted to Physician Compare, as well as the physician’s score in each of the four performance categories. MACRA gives CMS discretion to include scores for each individual measure within each performance category.
CMS previously has indicated its desire to establish a 5-star rating system for physicians and make it available to the public through Physician Compare. Once in place, MIPS composite scores will most likely provide the basis for assigning those star ratings. It is easy to imagine the many ways in which those star ratings will impact decisions regarding physicians, from patient choice to network eligibility.
CONCLUSION: PROVIDERS MUST IMPROVE SCORES ON KEY MEASURES
Unlike other industries, where the quality of a product or service directly impacts a business’ bottom line, healthcare providers have been paid almost exclusively based on the quantity of services provided. Now, with the arrival of publicly available data that allows objective, apples-to-apples comparisons, providers must identify and implement strategies and tactics to improve their scores on key measures. Your reputation—and your reimbursement— depend on it.
Contributed by Martie Ross, a principal at Pershing Yoakley & Associates, P.C. She advises providers navigating the ever-expanding maze of health-care regulations. Prior to PYA, she spent two decades as a health-care transactional and regulatory attorney.