Centers for Medicare

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Centers for Medicare Medicaid
ServicesCMS Progress Toward Implementing
Physician Resource Use Reports
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CMS Quality Improvement Roadmap

• Vision The right care for every person every
  time
• Make care
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

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CMS Quality Improvement Roadmap

• Strategies
• Work through partnerships
• Measure quality and report comparative results
• Value-Based Purchasing improve quality and
  avoid unnecessary costs
• Encourage adoption of effective health
  information technology
• Promote innovation and the evidence base for
  effective use of technology

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VBP Program Goals

• Improve clinical quality
• Reduce adverse events and improve patient safety
• Encourage patient-centered care
• Avoid unnecessary costs in the delivery of care
• Stimulate investments in effective structural
  components or systems
• Make performance results transparent and
  comprehensible
• To empower consumers to make value-based
  decisions about their health care
• To encourage hospitals and clinicians to improve
  quality of care the quality of care

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What Does VBP Mean to CMS?

• Transforming Medicare from a passive payer to an
  active purchaser of higher quality, more
  efficient health care
• Tools and initiatives for promoting better
  quality, while avoiding unnecessary costs
• Tools measurement, payment incentives, public
  reporting, conditions of participation, coverage
  policy, QIO program
• Initiatives pay for reporting, pay for
  performance, gainsharing, competitive bidding,
  bundled payment, coverage decisions, direct
  provider support

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Why VBP?

• Improve Quality
• Quality improvement opportunity
• Wennbergs Dartmouth Atlas on variation in care
• McGlynns NEJM findings on lack of evidence-based
  care
• IOMs Crossing the Quality Chasm findings
• Avoid Unnecessary Costs
• Medicares various fee-for-service fee schedules
  and prospective payment systems are based on
  resource consumption and quantity of care, NOT
  quality or unnecessary costs avoided
• Payment systems incentives are not aligned

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Practice Variation
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Practice Variation
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Why VBP?

• Medicare Solvency and Beneficiary Impact
• Expenditures up from 219 billion in 2000 to a
  projected 486 billion in 2009
• Part A Trust Fund
• Excess of expenditures over tax income in 2007
• Projected to be depleted by 2019
• Part B Trust Fund
• Expenditures increasing 11 per year over the
  last 6 years
• Medicare premiums, deductibles, and cost-sharing
  are projected to consume 28 of the average
  beneficiaries Social Security check in 2010

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Workers per Medicare Beneficiary
Source OACT CMS and SSA
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Support for VBP

• Presidents Budget
• FYs 2006-09
• Congressional Interest in P4P and Other
  Value-Based Purchasing Tools
• BIPA, MMA, DRA, TRCHA, MMSEA, MIPPA
• MedPAC Reports to Congress
• P4P recommendations related to quality,
  efficiency, health information technology, and
  payment reform
• IOM Reports
• P4P recommendations in To Err Is Human and
  Crossing the Quality Chasm
• Report, Rewarding Provider Performance Aligning
  Incentives in Medicare
• Private Sector
• Private health plans
• Employer coalitions

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VBP Demonstrations and Pilots

• Premier Hospital Quality Incentive Demonstration
• Physician Group Practice Demonstration
• Medicare Care Management Performance
  Demonstration
• Nursing Home Value-Based Purchasing Demonstration
  
• Home Health Pay for Performance Demonstration

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VBP Demonstrations and Pilots

• Medicare Health Support Pilots
• Care Management for High-Cost Beneficiaries
  Demonstration
• Medicare Healthcare Quality Demonstration
• Gainsharing Demonstrations
• Accountable Care Episode (ACE) Demonstration
• Better Quality Information (BQI) Pilots
• Electronic Health Records (EHR) Demonstration
• Medical Home Demonstration

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VBP Programs

• Hospital Quality Initiative Inpatient
  Outpatient Pay for Reporting
• Hospital VBP Plan Report to Congress
• Hospital-Acquired Conditions Present on
  Admission Indicator Reporting
• Physician Quality Reporting Initiative
• Physician Resource Use Reporting
• Home Health Care Pay for Reporting
• ESRD Pay for Performance
• Medicaid

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VBP Initiatives

• Physician Resource Use

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Efficiency in the Quality Context

• Efficiency Is One of the Institute of Medicine's
  Key Dimensions of Quality
• Safety
• Effectiveness
• Patient-Centeredness
• Timeliness
• Efficiency absence of waste, overuse, misuse,
  and errors
• Equity
• Institute of Medicine Crossing the Quality
  Chasm
• A New Health System for the 21st Century, March,
  2001.

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Resource Use Measurement

• Goals
• Measures that are meaningful, actionable, and
  fair
• Compare expected to actual resource use
• Link resource use to measures of quality and
  patient experiences of care

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Measurement Challenges

• Grouping claims into episodes of care
  -meaningfulness
• Attribution - assigning responsibility
• Benchmarks - making comparisons
• Risk adjustment - fairness
• Small numbers - reliability
• Feedback reports - actionability

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Episode of Care

• What is it?
• All clinical interactions with the patient
  regarding a specific health problem in a
  specified period of time.
• Why do it?
• More meaningful for a physician to be
  responsible for an episode than to be held
  responsible for all care a patient receives.
• How is it measured?
• Commercial episode grouper software future
  alternatives possible.

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Episode of Care

• What is the alternative?
• Per capita measuresAll costs of the patient,
  regardless of episode of care.
• Why use per capita measures?
• Better measure of total cost. Avoids problem of
  multiple brief episodes.
• How is it measured?
• Total cost of Medicare panel, divided by the
  size of the panel.

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Commercial Grouper Software

• Medical Episode Groups (MEGs)
• Thomson-Reuters (Medstat)
• Released in 1998, periodically updated
• 570 episode groups (MEGs)
• Based primarily on Dx codes

• Episode Treatment Groups (ETGs)
• United HealthCare (Ingenix/Symmetry)
• Released in early 1990s, periodically updated
• 465 base episode groups (ETGs)
• Based on Dx and procedure codes

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Episode Groupers and Medicare Claims Data

• Basics
• Cover both acute and chronic conditions
• A patient can have more than one episode at the
  same time

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Episode Groupers and Medicare Claims Data

• Types of claims
• Hospital (inpatient and outpatient)
• Physician
• Other Part B (DME)
• Excluded Medicare outpatient pharmacy claims
• Key data items
• Diagnosis codes
• Procedure and revenue codes (ETG only)
• Dates of service
• Payment amounts
• Site of service

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Episode Groupers and Medicare Claims Data

• Handling multiple services within a single claim
• Physicians and DME
• Divided into separate line item claims for each
  service
• Hospital (IP, OP), home health, SNF claims
• Lumped into a single cost

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Episode Timeline

Episode Duration
Episode initiating event
Clean Period
Some events are not part of this episode
Lookback period
. . .
. . .
Episode
Ancillary services--i.e., lab, radiology, etc.
Visit or procedure
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Episode Groupers and Medicare Claims Data

• How an episode begins
• ETG
• EM services, office visits, surgery, inpatient
  stay, SNF stay following a clean period
• MEG
• Physician visits or hospitalizations following a
  clean period
• Both
• May include lab tests and imaging services
  shortly before the first visit

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Episode Groupers and Medicare Claims Data

• How an episode ends
• Acute conditions months without a related
  claim (Clean period)
• Chronic conditions Ends after 1 year
• MEG only For 5 chronic conditions, acute
  exacerbations or flare-ups of a chronic condition
  are treated as an acute episode.

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Work in Progress

• Grouping Claims into Episodes
• Making commercial groupers and Medicare claims
  work together
• They can be made to work together, but the fit
  is not perfect.
• Assessing the clinical logic of commercial
  groupers
• Exploring alternative Medicare-oriented grouping
  strategies

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Work in Progress

• Testing Alternative Reports
• Physician feedback on resource use reports for
  imaging services (completed)
• Phase I Echocardiograms for Heart Failure
• Phase II MRs/CTs for Neck Pain
• Resource Use Report (RUR) pilot program

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Resource Use Reports for Imaging

• What We Learned
• Reports can identify outliers for educational
  intervention.
• Physicians need training in how to use reports.
• Reports should cover more than a single procedure
  or service.

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Statutory Authority MIPPA Section 131(c)

• RUR Pilot Program
• Medicare Improvement for Patients and Providers
  Act of 2008, Section 131(c)
• The Secretary shall establish a Physician
  Feedback Program under which the Secretary shall
  use claims data under this title (and may use
  other data) to provide confidential reports to
  physicians (and, as determined appropriate by the
  Secretary, to groups of physicians) that measure
  the resources involved in furnishing care to
  individuals under this title.
• If determined appropriate by the Secretary, the
  Secretary may include information on the quality
  of care furnished to individuals under this title
  by the physician (or group of physicians) in such
  reports.

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RUR Pilot Program

• Phase I (April 2008-March 2009)
• Use both ETG and MEG
• Standardize unit prices
• Assess several approaches to
• Risk-adjustment
• Attribution
• Benchmarks
• Produce alternative RURs for several acute and
  chronic conditions
• 1-on-1 interviews with small sample of providers
• Pilot-test with large sample of providers

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Creating Resource Use Reports
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Prepare claims data
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Group claims into episodes
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Risk-adjust the cost of each episode
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Attribute each episode to one or more physicians
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Calculate physicians efficiency score
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Compare score to a benchmark
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Produce and distribute RURs
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RUR Pilot Program

• Clinical conditions
• Acute conditions
• Community-acquired pneumonia (CAP)
• Urinary tract infection (UTI)
• Hip fracture
• Cholecystitis (may also be classified as chronic)
• Chronic conditions
• Congestive heart failure (CHF)
• Chronic obstructive pulmonary disease (COPD)
• Prostate cancer
• Coronary artery disease (CAD)/acute myocardial
  infarction (AMI)

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RUR Pilot Program

• Use both ETG and MEG episode groupers
• Process Medicare claims data to run optimally
  with each grouper
• Populate RURs with relative cost performance
  scores from either grouper
• Use only one grouper per RUR design
• Not evaluating which grouper is better

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RUR Pilot Program

• Standardize prices
• Required for benchmarking and risk adjustment
• Removes variation caused by GME and DSH payments
• Standardize to a base year (2006)
• Removes geographic variation in payment rates for
  specific goods and services
• Geographic Practice Cost Indices in physician
  fees
• Wage index and GAF in inpatient and other
  facility payments
• Variations in Carrier priced services.

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RUR Pilot Program

• Test alternative risk-adjustment approaches
• Model 1 Age, sex, severity level
• Model 2 Age, sex, severity level, and health
  status (HCC score)
• Model 3 Age, sex, severity level, health status
  (HCCs), and local area characteristics (county
  physician supply, income, and racial/ethnic
  demographics)

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RUR Pilot Program

• Test alternative risk-adjustment approaches
  Testing criteria
• Data test
• Precision Explanatory power of model to predict
  provider-level variation in costs
• Reliability Consistent ranking of providers by
  predicted cost
• Fairness Outlier providers identified and
  explained
• Field test
• Meaningful, actionable and fair Provider feedback

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RUR Pilot Program

• Test alternative attribution approaches
• Plurality-Minimum provider billing most EM
  visits and minimum percent episode costs
• Plurality-Established provider billing most
  established patient EM visits (chronic
  conditions only)
• Multiple-Even attribute entire cost of episode
  to each provider billing for any EM or procedure
  in the episode

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RUR Pilot Program

• Test alternative attribution approaches
  (continued)
• Multiple-Proportional attribute episode cost to
  each provider in proportion to billed visits in
  the episode
• First Contact attribute entire episode cost to
  provider billing first EM for the episode (acute
  episodes only)

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RUR Pilot Program

• Test alternative attribution approaches Testing
  criteria
• Data test
• Comprehensive Maximize number of episodes that
  can be attributed to providers
• Fair Ensure that providers have reasonable
  control over clinical decisions for episodes to
  which they are assigned
• Reliable Consistency of rankings across
  alternative rules
• Field test
• Meaningful, actionable and fair Provider feedback

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RUR Pilot Program

• Test alternative benchmarks
• Cut-point for defining cost-inefficient providers
• Norm (mean/median provider)
• Best performance (least cost providers)
• Outliers (highest cost providers)
• Geographic scope of peer group
• National
• State
• Hospital Service Area (HSA)
• Provider group (TIN)
• Specialty scope of peer group
• Same (narrow) medical specialty
• Broad specialty group
• Other medical specialties but same episode profile

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Phase I Round I Options Tested forPer Capita
Resource Use Costs
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RUR Pilot Program

• Test alternative benchmarks Testing criteria
• Data-test benchmark rules
• Fairness Number and characteristics of outliers
• Reliability Stability of outliers over time and
  by rule
• Precision Statistical properties of scores
  Precision, distribution of episodes
• Consistency Comparing scores based on
  alternative benchmarks
• Field-test several benchmarking rules in RURs
• Meaningful, actionable and fair Provider feedback

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RUR Pilot Program

• Outreach and coordination
• Goals
• Request technical assistance from stakeholders
• Provide transparency
• Coordinate with other federal efforts

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RUR Pilot Program

• Outreach and coordination
• Presentations to, and feedback from, stakeholder
  groups
• Providers
• Consensus-based organizations
• Consumers
• Payers
• Purchasers
• Accreditation and standards organizations

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RUR Pilot Program

• Field testing
• 3 waves of 1-on-1 interviews with small samples
  of providers
• Provider feedback on alternative RURs
• Risk adjustment
• Attribution
• Benchmarks
• Per capita measures
• Type of cost/service drill down
• RUR layout
• Analyze results eliminate some alternatives for
  pilot testing

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RUR Pilot Program

• Pilot testing
• Distribute RURs to a large sample of providers in
  12 pilot sites
• Provider feedback on-line, e-mail, hard copy
• Revise RURs based on provider feedback

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RUR Pilot Program

• Potential next phase
• Explore combining efficiency measures with
  quality measures
• Develop and test composite measures
• Continue to improve the validity, usability, and
  fairness of RURs
• Scale-up if warranted