By: Theresa Hush, CEO & Co-Founder, ICLOPS

Centers for Medicare and Medicaid Services (CMS) won’t be the only group scrutinizing your quality and cost data anymore. As the next step toward value-based healthcare, Medicare has begun publishing provider performance data for PQRS under Physician Compare. Now patients and their families can make their own data-driven choices about healthcare providers with an online search.

The website is a game-changer. Performance variation between providers is startling. There are 50 provider groups with performance at or lower than 65% for at least one published measure. By contrast, a handful of groups show all four measures over 95 percent. The 2013 data are limited and do not include all providers. Yet the information provides a powerful first impression.

Based on the data, would an internet-savvy family member try to convince a parent to leave you? Take notice, physicians and health systems: Data will drive business.

At a Glance: Physician Compare Data for PQRS

Physician Compare is still evolving in scope of data publication while Medicare continues tweaking its calculations to instill more fairness and accuracy. Nevertheless, publication has begun and benchmarks are under discussion for the future. For PQRS measurement year 2013, this is what was on the site in July:

♦  623 Provider Groups who Reported PQRS or eRx in 2013 are listed
♦  Of the 623 Groups, Medicare published data for 138
♦  Data is only for groups which reported through the Group Reporting Option (GPRO) Web Interface
♦  Aggregate data for four (of 22) GPRO PQRS measures are published for each group:

° Prescribing aspirin to patients with diabetes and heart disease
° Prescribing medicine to improve the pumping action of the heart in patients who have both heart disease and certain other conditions
° Controlling blood sugar for patients with diabetes
° Controlling blood pressure in patients with diabetes

♦  The published measure data is specific to the group’s performance

Physician Compare also has other data on providers, such as a list of all providers, whether they accept Medicare assignment, their specialties, and in which of the quality programs they chose to participate. As the site and Medicare’s programs develop, Physician Compare will undoubtedly become a primary source of physician quality, cost, and Medicare participation data.

Improve Your Standing in the Public Data

Published data has some important implications for how providers should manage their public image. Although Physician Compare will change significantly in the future, this is how to help manage your situation now:

♦  Evaluate: Data and Patient Attribution. All Medicare value-based healthcare programs, including ACOs, use an algorithm to assign the patients in your sample to you. Groups which report through the GPRO web interface tend to be large multi-specialty or academic groups, with high numbers of specialists. You may not actually be managing patients for the conditions being reported, yet you could be the attributed provider.

♦  Reevaluate: PQRS Reporting Options.  Medicare restricted 2013 data publication to only groups reporting through the GPRO web interface method of PQRS reporting. That will change. But you may wish to evaluate your use of this option and GPRO Registry reporting instead for several reasons.

° First, be wary of reporting on only a sample of patients for quality data submittal. It can be a disadvantage. With an unknown effect on your total performance scores, why take a chance you will lower your public performance profile?

° Second, Medicare has probably started with GPRO Web Interface because the measures are the same for all providers and therefore easier to compare, but keep in mind the likelihood all Medicare performance will eventually be published. Consider whether you want to self-select your organization for publication by choosing this reporting method.

Evaluating the patient data through a Registry may suggest a path to improve attribution by coordinating care with referring primary care physicians or your own primaries. This will be especially important for avoiding penalties under the Value-Based Payment Modifier (VBPM), where your quality and cost calculations will be compared against other groups. The VBPM has a similar attribution methodology, so taking action to make sure your specialty patients have (and see) a primary care coordinator will help you.

♦   Use a Registry to measure your performance for all patients, including Medicare beneficiaries on an ongoing basis. While Medicare may be ahead of the curve in publishing performance, health plans and employers are contracting on the basis of quality and cost. Most large groups decided to use the GPRO Web Interface because it seemed easy and avoided either building or buying technology.

Consider whether avoiding $50,000 or more investment in PQRS Reporting (depending on your size) is worth the risk of losing several million in penalties under the VBPM. These are related—if your publicly reported performance is lower than your peers, your quality score under the VBPM is likely to be, too. And how much more will your revenues decline by the movement of your patients to higher performing groups?

Public reporting will grow gradually, but it will not take long before patients and families are ready to trust data rather than word-of-mouth in choosing providers. From which point, we can also imagine Medicare patients could be offered a financial incentive to use higher performing/lower cost groups for healthcare services.

Likewise, cost-conscious ACOs and non-participating primary care or specialty groups—also with access to Physician Compare data—have a built-in incentive to use the data to alter their referral profiles. Because of the Medicare VBPM and ACO attribution methodologies, which are aligned, both groups have the motivation to reduce their total costs per beneficiaries, avoid penalties, and achieve incentive monies or shared savings.

Many large systems are beginning to form ACOs or develop methods of internally measuring performance, but we’re still far from the goal. Comparative data is a moving target—performance must always improve in order to keep pace with the competition. Medicare’s publication of performance data, coupled with VBPM penalties and ACO risk, will put pressure on groups to monitor their performance data along with social reputation. It will be the key to involving patients in decisions about where to seek “value” in their healthcare.

Theresa Hush is a healthcare strategist and change expert with experience across the healthcare spectrum. Her many accomplishments in the public, non-profit and private sectors include leading the transformation of Blue Cross Blue Shield regulations in Illinois, improving access to care as Director of the Illinois Medicaid program, and serving in executive leadership for both private payers and physician organizations. An expert at creating consensus for desired change through education and collaboration, Terry helps organizations take actions that will direct their future through meaningful technology and programs.