Medicare Physician Feedback Program:

CMS Faces Challenges with Methodology and Distribution of Physician Reports

GAO-11-720: Published: Aug 12, 2011. Publicly Released: Aug 12, 2011.

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The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) directed the Department of Health and Human Services (HHS) to develop a program to give physicians confidential feedback on the resources used to provide care to Medicare beneficiaries. In response, HHS's Centers for Medicare & Medicaid Services (CMS) has established and implemented the Physician Feedback Program by distributing feedback reports to an increasing number of physicians that provided data on resources used and the quality of care. MIPPA mandated that GAO conduct a study of this program. To address this mandate, GAO identified (1) methodological challenges CMS faces in developing feedback reports and approaches CMS has tested to address them and (2) challenges CMS faces in distributing feedback reports and CMS's plans to address them. GAO interviewed CMS officials and representatives from the program contractor and reviewed relevant documentation.

CMS faces challenges incorporating resource use and quality measures for physician feedback reports that are meaningful, actionable, and reliable. CMS had difficulty measuring the resources used by physicians to treat specific episodes of an illness, such as a stroke or a hip fracture, and the quality measures it used in the program's most recent phase applied to a limited number of physicians. CMS must also make decisions to address several other methodological challenges with developing feedback reports: how to account for differences in beneficiary health status, how to attribute beneficiaries to physicians, how to determine the minimum number of beneficiaries a physician needs to treat to receive a report, and how to select physicians' peer groups for comparison. These decisions involve trade-offs; for example, a higher minimum case size requirement increases the reliability of the information in the reports, but it decreases the number of physicians eligible to receive one. While CMS has tested different approaches to measuring and comparing physician performance, methodological difficulties remain in developing feedback reports. CMS also faced challenges distributing feedback reports to physicians that its plans for improvement may not entirely address. In the most recent phase of the program, about 82 percent of physicians in CMS's sample were not eligible to receive a report after CMS's methodological decisions were applied. CMS plans to make a number of methodological changes in the next phase, but significantly increasing eligibility will continue to be challenging. The electronic distribution of feedback reports also presented multiple challenges that resulted in few physicians accessing their electronic reports in the most recent phase. Factors that may have contributed to this low access rate include CMS's difficulty in obtaining accurate contact information, burdensome methods for electronic distribution, and lack of a strong incentive for physicians to review their reports. CMS conducted limited follow-up with physicians for whom feedback reports were produced. CMS plans to use a new distribution method in a four-state region in the next reporting phase. GAO is recommending that CMS use methodological approaches that increase physician eligibility for reports, statistically analyze the impact of its methodological decisions on report reliability, identify and address factors that may have prevented physicians from reading reports, and obtain input from a sample of physicians on the usefulness and credibility of reports. CMS concurred with these recommendations.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In response to our recommendation, CMS stated that it has expanded the provision of reports to smaller groups of physicians and is developing the processes needed to provide reports to all physicians and physician groups in 2014. The agency reported that this has been accomplished by expanding eligibility to non-physicians, such as nurse practitioners, and by using different attribution methods. This effort is consistent with the requirement in the Patient Protection and Affordable Care, which requires HHS to adjust Medicare payments to all physician based on the quality of their care compared to their cost by 2017. The agency will use the measures in the feedback reports as the basis for this differential payment.

    Recommendation: In order to develop feedback reports that are more reliable, credible, accessible, and applicable to a greater number of Medicare physicians, the Administrator of CMS should use methodological approaches that increase the number of physicians eligible to receive a report, such as (1) multiple provider attribution methods, which could also enhance credibility of the reports with physicians and (2) distributing feedback reports that include only resource use information, if quality information is unavailable.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  2. Status: Closed - Implemented

    Comments: In the 2014 Notice of Proposed Rulemaking, CMS noted that it conducted reliability analyses for the quality measures contained in the 2011 and 2012 feedback reports, and found that its current minimum size of 20 cases for its quality measures resulted in high reliability. The agency stated that it will continue to assess the reliability of performance measures in the future and report the results in proposed regulations. The agency stated that GAO's recommendation motivated the additional reliability testing the agency conducted.

    Recommendation: In order to develop feedback reports that are more reliable, credible, accessible, and applicable to a greater number of Medicare physicians, the Administrator of CMS should conduct statistical analyses of the impact of key methodological decisions on reliability.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  3. Status: Closed - Implemented

    Comments: CMS stated that it routinely monitors the number of physicians who access their feedback reports and has taken steps to improve physician access. CMS stated that the use of the web-based portal, which physicians use to access their reports, has increased the number of physician accessing their reports. In addition, CMS has held a national provider call and conducted outreach with physician groups and relevant specialty societies as part of its efforts to encourage greater number of physicians to access their reports.

    Recommendation: In order to develop feedback reports that are more reliable, credible, accessible, and applicable to a greater number of Medicare physicians, the Administrator of CMS should identify factors that may have prevented physicians from accessing their reports and, as applicable, develop strategies to improve the process for distributing reports and facilitating physicians' access to them.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  4. Status: Closed - Implemented

    Comments: In response to our recommendation, CMS took steps to ensure that feedback reports were meaningful and actionable to physicians by obtaining input from physicians who received feedback reports and from relevant specialty societies, including the American Medical Association. These meetings have resulted in changes to the 2012 and 2013 feedback reports, such as the inclusion of additional information on the health status of physicians' patients and the nature of hospital admissions.

    Recommendation: In order to develop feedback reports that are more reliable, credible, accessible, and applicable to a greater number of Medicare physicians, the Administrator of CMS should obtain input from a sample of physicians who received feedback reports on the usefulness and credibility of the performance measures contained in the reports and consider using this information to revise future reports.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

 

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