The Brave New World of Medicare Physician Payment: The Quality & Resource Use Report and What You Must do before March

In 2015, the Centers for Medicare & Medicaid Services (CMS) for the first time distributed Quality and Resource Use Reports (QRURs) to all physicians in the country. 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 to be adjusted. (They could stay the same, get reduced, or get a bonus. Note that everyone is affected. Some effects are neutral.) The VM calculations are based on a provider’s quality and cost performance when compared to their “peers.” 

EPs will be subject to the VM in 2017, the year the Merit-Based Payment Incentive System (MIPS) kicks in.¹ MIPS rolls all three quality programs (Physician Quality Reporting System [PQRS], Meaningful Use, and VM) into one. 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 must pick your PQRS quality measures immediately. Additionally, you have until the last day of February to sign up with a specialty registry in order to achieve Meaningful Use Objective 10 - Public Health and Clinical Data Registry Reporting. If you reported PQRS in 2014, you can preview the VM methodology 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 personal blog (https://carolinefifemd.com). The 2014 QRUR uses your PQRS data to determine your “quality” performance, plus a quality metric CMS created based on claims data. Then, to calculate your “cost” performance, CMS first identifies patients based on 64 conditions that it’s tracking on inpatients, some of whom represent major surgical procedures (eg, breast reconstruction, heart valve repair) and some of whom represent medical conditions (eg, 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 nondiabetic patient living with cellulitis. 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 based on who billed the “plurality” of evaluation and management (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 in long-term acute care or hospice. After that, CMS compares the Medicare charges of “your” patients over their episodes 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 these conditions.

Here’s the spoiler alert to what I will post on my blog: CMS found 21 inpatients living with the conditions they have prioritized for whom they decided I was the “primary care provider” based on the percentage 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 clinic after hospital discharge, but clearly their “episode of care” included this timeframe. The charges generated in the care of those patients were compared to primary care doctors in the United States. The good news is that I did not have enough patients in any individual category (eg, heart failure) for CMS to produce a cost report for me. The most chilling parts of my QRUR were the additional tables that showed 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 I was overusing post-acute services and doing too many minor surgical procedures. To me, conditions like heart failure were comorbidities. 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. Cost benchmarks are based on the national mean of performance rates during the current performance year. 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 online at www.cms.gov.

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: Report wound care and hyperbaric medicine-specific quality measures through organizations like the US Wound Registry (USWR). In 2014, the only reporting option I had was to report standard PQRS measures, so my peer group is all the family-practice physicians 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 most powerful argument for specialty registry reporting through the USWR. For 2016, I am going to report a few standard PQRS measures (such PQRS No. 1 - Diabetes: Hemoglobin A1c Poor Control), and the rest of the measures will be wound care- and hyperbaric medicine-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 EPs in the country. Choose your PQRS measures wisely. A lot is riding on PQRS performance. Your best option is to report wound- and hyperbaric medicine-specific quality measures through a registry. 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’ve stated.

If you don’t sign up to work with a specialty registry by Feb. 29, you will fail Objective 10 of Meaningful Use, which will affect your MIPS score. 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 Annual QRURs and Supplementary Exhibits at www.cms.gov.

Caroline E. Fife, MD, FAAFP, CWS, FUHM, is chief medical officer at Intellicure Inc.; executive director of US Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands, TX; and co-chair of the Alliance of Wound Care Stakeholders.

Reference

1. Fife CE. The truth about ‘wound healing rates.’ TWC. 2015;9(4):4.