The Brave New World of Medicare Physician Payment: The Quality and Resource Use Report and what you need to do before the end of February

Jan-6-162015 is the first year that CMS has distributed Quality and Resource Use Reports (QRURs) to all physicians in the USA. Made available in early September, the QRUR is a confidential report that reflects the quality and cost measure data collected by an eligible provider (EP) to Medicare fee-for-service patients. Some of the information in the QRUR is used by CMS to calculate the Physician Value-Based Payment Modifier (VM).  The VM is then used to determine whether the EP’s Medicare payments are adjusted (they could stay the same, get reduced or get a bonus).  The VM calculations are based on a provider’s quality and cost performance when compared to their “peers.”

EPs will start being subject to the VM next year, in 2017, the year that MIPS kicks in. MIPS, the Merit-Based Incentive Payment System (see my previous editorial about that) rolls all 3 quality programs into one big program (PQRS, Meaningful Use of an EHR and the VM). Success with PQRS is an absolute necessity to survive the transition to the new payment model because it is the way “quality” is defined for all the components of the program. It is critical that all providers participate in PQRS. You need to pick your PQRS quality measures right now. And, you have until the last day of February to sign up with a Specialty Registry in order to achieve Objective 10, Meaningful Use of an EHR.

If you reported PQRS in 2014, you can get a preview of the VM methodology that CMS will apply in 2017. I spent part of my Christmas holiday analyzing my QRUR report and what I found is surprising and worrisome for wound care practitioners, so I decided to post the results of my QRUR on my blog. The 2014 QRUR uses your PQRS data to determine your “quality” performance, plus a quality metric that CMS created based on claims data. Then, to calculate your “cost” performance, CMS first identifies patients based on 64 conditions that it is tracking on INPATIENTS, some of which are major surgical procedures (e.g. breast reconstruction, heart valve repair) and some of which are medical conditions (e.g. cellulitis, heart failure). Most of our patients are going to be identified based on the medical conditions for which they will be hospitalized, unrelated to their wounds. The only condition related to a wound is a non-diabetic with cellulitis and ironically, since none of my wound patients were hospitalized with cellulitis, none of the patients who contributed to my cost data were selected on the basis of anything relating the WOUND but rather because of a hospitalization for one of their underlying medical problems.  CMS then identifies the primary doctor by finding the doctor who billed the “plurality” of E&M services during the “episode of care” for that condition. The episode can include a few days prior to the admission and the post acute treatment including treatment at long term acute care or hospice. After that, they compare the Medicare charges of “your” patients over their episode of care to the charges incurred by patients of your “peers”. Your peers are the other clinicians who provided E&M services to patients with those conditions.

Here’s the spoiler alert to what I will post on my blog. CMS found 21 inpatients with the conditions they have prioritized for whom they decided I was the “primary care provider” based on the % of E&M charges I billed compared to the other physicians caring for them. It goes without saying that I was NOT the primary care physician of any of those patients, nor was I their attending physician in the hospital. My interaction with them was entirely in the outpatient wound center after hospital discharge, but clearly their “episode of care” included this time frame. The charges generated in the care of those patients were compared to primary care doctors in the USA. The good news is that I did not have enough patients in any individual category (e.g. heart failure) for CMS to produce a cost report for me.

The most chilling part of my QRUR were the additional tables which showed that the patients I cared for had unusually high charges for post-acute care services and minor surgical procedures compared to my “peers.” Why? Because I was being compared to primary care physicians across the country who were actually treating heart failure. Naturally, since I saw all of my patients in a hospital based outpatient clinic for their wounds, it appeared that I was over-using post-acute services and doing too many minor surgical procedures. To me, conditions like heart failure were co-morbidities. In the QRUR, they are the basis for the cost report.

Quality benchmarks are based on the national mean of each measure’s performance rate during the year prior to the performance year (i.e., 2013 data). Cost benchmarks are based on the national mean of performance rates during the current performance year (i.e., 2014 data). All cost measures are payment standardized to adjust for geographic differences, risk adjusted based on patient characteristics, and adjusted to reflect the specialty mix of professionals in the group. Detailed methodology information is available on the CMS website (Detailed Methodology for the 2016 VM and the 2014 QRUR).

Where do we go from here?

There is an old joke about being tried by a jury of your peers. The punch line is, “Who wants to be tried by 12 people not smart enough to get out of jury duty?” There is only one way to create a peer group for wound and hyperbaric providers in the quality arena and that is to report wound care and hyperbaric medicine specific quality measures through the US Wound Registry. In 2014, the only reporting option that I had was to report standard PQRS measures, so my peer group is all the family practice physician who reported those measures. I can at least fix the peer group issue with regard to quality by creating a peer group with a specialty registry. This is the single most powerful argument for specialty registry reporting through the USWR. This year, in 2016, I am going to report a few standard PQRS measures (like PQRS #1, Hemoglobin A1C) and the rest of the measures will be wound care and hyperbaric specific measures through the USWR. My peer group will be the other wound care and hyperbaric medicine providers doing the same, rather than all the FPs in the USA.

Choose your PQRS measures wisely. A lot is riding on PQRS performance. Your best option is to report wound and hyperbaric specific quality measures through the USWR but failing that, if you are going to use standard PQRS measures like I did in 2014 (because that is all I had to choose from in 2014), then understand that your performance will be compared to all the other physicians in your primary specialty reporting those measures. You can also get through PQRS in 2016 by reporting the Diabetes Measure Group in only 20 patients. It’s the easiest way to survive in 2016 but it’s not the best long term plan for the reasons I have stated above.

Sign up for Specialty Registry Reporting by February 29, 2016. That is only days away. If you do not sign up to work with a specialty registry by the last day of February, you will fail Objective 10 of Meaningful Use and that will affect your MIPS score. Call the USWR. Simply getting signed up meets the definition of being “engaged” in registry reporting (at least for the time being).

Download your own QRUR report. For step-by-step instructions, refer to the “Guide for Accessing the 2014 Supplemental QRURs” on the “How to Obtain a QRUR” webpage

Caroline Fife, MD

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