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    Subject Term: "Hospital care services"

    18 publications with a total of 30 open recommendations including 9 priority recommendations
    Director: James Cosgrove
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To ensure that the HVBP program accomplishes its goal to balance quality and efficiency and to ensure that it minimizes the payment of bonuses to hospitals with lower quality scores, the Administrator of CMS should revise the formula for the calculation of hospitals' total performance score or take other actions so that the efficiency score does not have a disproportionate effect on the total performance score.

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

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To ensure that the HVBP program accomplishes its goal to balance quality and efficiency and to ensure that it minimizes the payment of bonuses to hospitals with lower quality scores, the Administrator of CMS should revise the practice of proportional redistribution used to correct for missing domain scores so that it no longer facilitates the awarding of bonuses to hospitals with lower quality scores.

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

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Katherine Iritani
    Phone: (202) 512-7114

    2 open recommendations
    including 2 priority recommendations
    Recommendation: To ensure efficient use of federal resources, the Administrator of CMS should improve alignment of Medicare UC payments with hospital uncompensated care costs by basing these payments on hospital uncompensated care costs.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: The Department of Health and Human Services concurred with this recommendation and indicated that the agency planned to implement it beginning in fiscal year 2021 to allow time for hospitals to collect and report reliable uncompensated care cost data. We believe this action could be implemented sooner.
    Recommendation: To ensure efficient use of federal resources, the Administrator of CMS should account for Medicaid payments a hospital has received that offset uncompensated care costs when determining hospital uncompensated care costs for the purposes of making Medicare UC payments to individual hospitals.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: The Department of Health and Human Services concurred with this recommendation and indicated that the agency planned to implement it beginning in fiscal year 2021 to allow time for hospitals to collect and report reliable uncompensated care cost data. We believe this action could be implemented sooner.
    Director: Randall B. Williamson
    Phone: (202) 512-7114

    1 open recommendations
    including 1 priority recommendation
    Recommendation: To help provide reasonable assurance that VHA achieves its long-term goal of modernizing its claims processing system, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that the agency develops a sound written plan that includes the following elements: (1) a detailed schedule for when VHA intends to complete development and implementation of each major aspect of its new claims processing system; (2) the estimated costs for implementing each major aspect of the system; and (3) the performance goals, measures, and interim milestones that VHA will use to evaluate progress, hold staff accountable for achieving desired results, and report to stakeholders the agency's progress in modernizing its claims processing system.

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: As of June 2017, VHA's Office of Community Care is in the process of consolidating VA's community care programs, and as part of this process it plans to transition to a third party administrator for the purposes of claims processing. While an active procurement is underway, VHA still needs to develop a written plan to fully implement this recommendation. VHA's written plan must include details about the schedule, cost estimates, performance goals, and interim milestones associated with transitioning to a third party administrator for the purposes of processing claims for VA community care.
    Director: James Cosgrove
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: The Secretary of Health and Human Services should direct the Administrator of CMS to assess the feasibility of updating the agency's study on the effect of VA-provided Medicare-covered services on per capita county Medicare FFS spending rates by obtaining VA utilization and diagnosis data for veterans enrolled in Medicare FFS under its existing data use agreement or by other means as necessary.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In July 2016, the U.S. Department of Health and Human Services (HHS) reiterated its disagreement with our recommendation. HHS stated that the Centers for Medicare & Medicaid Services (CMS) uses Medicare fee-or-service(FFS) spending rates when setting the benchmark, which excludes services provided by Department of Veterans Affairs (VA) facilities. In addition, HHS stated that incorporating VA utilization and diagnosis data into CMS's analysis may not materially improve the analysis and the resulting adjustment. HHS indicated that it will continue to review the need for incorporating additional data or for methodology changes in the future. As we note in the report, only VA's utilization and diagnosis data can account for services provided by and diagnoses made by VA. Depending on the number and mix of services provided by and the diagnoses made by VA, risk-adjusted Medicare FFS spending for veterans may either be higher or lower than it would be if CMS accounted for VA-provided services and diagnoses. Therefore, relying exclusively on Medicare FFS spending to estimate the effect of VA spending on Medicare FFS-enrolled veterans could result in an inaccurate estimate of how VA spending on services for Medicare FFS-enrolled veterans affects per capita county Medicare FFS spending. While there may be challenges associated with incorporating VA utilization and diagnosis data into CMS's analysis, we maintain that CMS should work to do so given the implications that not incorporating the data may have on the accuracy of payment to MA plans.
    Recommendation: If CMS makes an adjustment to the benchmark to account for VA spending on Medicare-covered services, the Secretary of Health and Human Services should direct the Administrator of CMS to assess whether an additional adjustment to MA payments is needed to ensure that payments to MA plans are equitable for veterans and nonveterans.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: The Department of Health and Human Services (HHS)has proposed adjusting the benchmark for 2017 to account for the Department of Veterans Affairs (VA) spending on Medicare-covered services. As of July 2016, HHS had not yet completed its assessment of whether an additional adjustment to MA payments is needed to ensure that payment to Medicare Advantage (MA) plans are equitable for veterans and nonveterans. In order to close this recommendation, CMS will need to complete its assessment.
    Director: Kathleen King
    Phone: (202) 512-7114

    1 open recommendations
    including 1 priority recommendation
    Recommendation: To help ensure that timely primary care is available and accessible to AI/AN people, the Secretary of HHS should direct the Director of IHS to monitor patient wait times in its federally operated facilities and ensure corrective actions are taken when standards are not met.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: As of June 2017, according to IHS, the implementation of an agency-wide standard for patient wait times will be accomplished as follows: A decision will be made on the standard to be used, by the IHS Director no later than July 2017. Using a pilot sample of facilities (two to four facilities), the standard will be assigned to the Area Directors over the selected pilot facilities in October 2017. Systems of measurement will be decided and communicated to the Area Directors for the pilot facilities. By December 31, 2017, three months of activity will be analyzed and evaluated against the standard. Between January and March, 2018, adjustments to the necessary systems of measure, or adjustments to the reasonably expected performance standard will be made. A final evaluation will be performed not later than September 2018, and final adjustments will be made to either the measurement system or the standard to allow for full implementation of the standard across all IHS Areas by October, 2018.
    Director: Katherine Iritani
    Phone: (202) 512-7114

    2 open recommendations
    including 2 priority recommendations
    Recommendation: To promote consistency in the distribution of supplemental payments among states and with CMS policy, the Administrator of CMS should issue written guidance clarifying its policy that requires a link between the distribution of supplemental payments and the provision of Medicaid-covered services.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: CMS plans to publish a proposed rule for public comment in the summer of 2017 to improve the oversight of supplemental payments, including a proposal to require that supplemental payments be distributed proportional to the volume or cost of services delivered or be tied to meeting performance benchmarks. To the extent the agency issues a final rule that results in states distributing supplemental payments in a manner that aligns their distribution with individual facilities' Medicaid workloads, CMS's ability to ensure that state Medicaid payments are not excessive and are used for Medicaid purposes will improve.
    Recommendation: To promote consistency in the distribution of supplemental payments among states and with CMS policy, the Administrator of CMS should issue written guidance clarifying its policy that payments should not be made contingent on the availability of local funding.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: CMS plans to publish a proposed rule for public comment in the summer of 2017 to improve the oversight of supplemental payments, including a proposal to require that supplemental payments be distributed proportional to the volume or cost of services delivered or be tied to meeting performance benchmarksTo the extent the agency issues a final rule that results in states distributing supplemental payments in a manner that aligns their distribution with individual facilities' Medicaid workloads, CMS's ability to ensure that state Medicaid payments are not excessive and are used for Medicaid purposes will improve.
    Director: James Cosgrove
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To help ensure the financial sustainability of the Medicare program, protect beneficiaries from unwarranted financial burden, and address potential concerns about the appropriateness of the health care provided to Part B beneficiaries, Congress should consider eliminating the incentive to prescribe more drugs or more expensive drugs than necessary to treat Medicare Part B beneficiaries at 340B hospitals.

    Agency: Congress
    Status: Open

    Comments: As of February 2017, no action had been taken on this Matter for Congressional Consideration.
    Director: Kathleen M. King
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: CMS should conduct a formal analysis, using its experience and data it has collected since the implementation of the first MAC contracts, to determine whether alternative contracting approaches could be used--even if only for selected MAC contract responsibilities--to help promote improved contractor performance.

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

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: James Cosgrove
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To help the Department of Health and Human Services better control spending and encourage efficient delivery of care, Congress should consider requiring Medicare to pay PCHs as it pays PPS teaching hospitals, or provide the Secretary with the authority to otherwise modify how Medicare pays PCHs. To generate cost savings from any reduction in outpatient payments to PCHs, Congress should also provide that all forgone outpatient payment adjustment amounts be returned to the Supplementary Medical Insurance Trust Fund.

    Agency: Congress
    Status: Open

    Comments: The 21st Century Cures Act enacted in December 2016 slightly reduces the additional payments to PCHs for outpatient services furnished on or after January 1, 2018, and returns savings to the Supplementary Medical Insurance Trust Fund. However, the law does not substantively change how PCHs are paid for outpatient services, which differs from how Medicare pays PPS teaching hospitals. In addition, as of March 1, 2017, no legislative action had been identified that changes how PCHs are paid for inpatient services, as GAO suggested in February 2015. Until Medicare pays these cancer hospitals in a way that encourages greater efficiency, Medicare remains at risk for overspending.
    Director: Linda T. Kohn
    Phone: (202) 512-7114

    4 open recommendations
    Recommendation: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to include in the CMS Compare websites, to the extent feasible, estimated out-of-pocket costs for Medicare beneficiaries for common treatments that can be planned in advance.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2015 CMS indicated that it is working to implement this recommendation. Specifically, it is actively investigating options for allowing a more targeted and consumer-centric individual user experience on Physician Compare. We will follow up to gather additional information from CMS officials as they continue their work.
    Recommendation: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to organize cost and quality information in the CMS Compare websites to facilitate consumer identification of the highest-performing providers, such as by listing providers in order based on their performance.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2015, CMS indicated that it is working to implement this recommendation. We will follow up to gather additional information from CMS officials as they continue their work.
    Recommendation: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to include in the CMS Compare websites the capability for consumers to customize the information presented, to better focus on information relevant to them.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2015, CMS indicated that it is working to implement this recommendation. Specifically, it is evaluating feasibility of including estimated out-of-pocket costs on physician compare. We will follow up to gather additional information from CMS officials as they continue their work.
    Recommendation: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to develop specific procedures and performance metrics to ensure that CMS's efforts to promote the development and use of its own and others' transparency tools adequately address the needs of consumers.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2015, CMS indicated that it is working to implement this recommendation. CMS also noted that Physician Compare is in the early stages of public reporting, and is evaluating the feasibility of listing providers based on their performance in the new carefinder.gov project. We will follow up to gather additional information from CMS officials as they continue their work.
    Director: Debra A. Draper
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To help ensure adequate and qualified nurse staffing at VAMCs, the Secretary of Veterans Affairs should direct the Interim Under Secretary for Health to enhance VHA's internal controls by completing evaluations of Phase I and Phase II and make any necessary changes to policies and procedures before national implementation of Phase II in all VAMCs.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA agreed with this recommendation and, according to an update received April 2017, VA is taking actions towards addressing this recommendation and expects to complete those actions Fall 2017. When additional information is received GAO will update the recommendation as appropriate.
    Director: Cosgrove, James C
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To increase beneficiaries' awareness of providers' financial interest in a particular treatment, Congress should consider directing the Secretary of Health and Human Services to require providers who self-refer IMRT services to disclose to their patients that they have a financial interest in the service.

    Agency: Congress
    Status: Open

    Comments: In August 2013, to increase beneficiaries' awareness of providers' financial interest in a particular treatment, we suggested that Congress should consider directing the Secretary of Health and Human Services to require providers who self-refer IMRT services to disclose to their patients that they have a financial interest in the service. As of June 2017, Congress has not implemented this suggestion.
    Recommendation: The Administrator of CMS should insert a self-referral flag on its Medicare Part B claims form, require providers to indicate whether the IMRT service for which a provider bills Medicare is self-referred, and monitor the effects that self-referral has on costs and beneficiary treatment selection.

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

    Comments: In August 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) insert a self-referral flag on its Medicare Part B claims form, require providers to indicate whether the intensity-modulated radiation therapy (IMRT) service for which a provider bills Medicare is self-referred, and monitor the effects that self-referral has on costs and beneficiary treatment selection. The Department of Health and Human Services (HHS) did not concur with this recommendation, noting that CMS does not believe that this recommendation will address overutilization that occurs as a result of self-referral, would be complex to administer, and may have unintended consequences. We continue to believe that such a flag on Part B claims would likely be the easiest and most cost-effective way for CMS to identify self-referred IMRT services and monitor the effects of self-referral. As of June 2017, CMS has not provided any additional information about actions it has taken to address this recommendation.
    Director: Cosgrove, James C
    Phone: (202)512-7029

    3 open recommendations
    including 3 priority recommendations
    Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should insert a self-referral flag on its Medicare Part B claims form and require providers to indicate whether the advanced imaging services for which a provider bills Medicare are self-referred or not.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: HHS did not concur with this recommendation, noting that CMS did not think this recommendation would be effective in addressing overutilization resulting from self-referral and that it would be complex to administer. We continue to believe that such a flag on Part B claims would likely be the easiest and most cost-effective way for CMS to identify self-referred advanced imaging services and monitor the behavior of those providers who self-refer these services even though the agency has no plans to take further action. As of October 2016, CMS has not provided any additional information about actions to address this recommendation.
    Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should determine and implement a payment reduction for self-referred advanced imaging services to recognize efficiencies when the same provider refers and performs a service.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: HHS did not concur with this recommendation, noting that CMS did not believe that a payment reduction would address overutilization that occurs as a result of self-referral and that the agency's multiple procedure payment reduction policy for advanced imaging already captures efficiencies inhering in providing multiple advanced imaging services by the same physician. Further, CMS officials stated that providers in self-referring arrangements could avoid this reduction by having one provider refer an advanced imaging service while having another perform the service. Finally, CMS questioned whether implementing our recommendation would violate the Medicare statute prohibiting paying a differential by physician specialty for the same service. Our recommendation, however, refers to specific self-referral arrangements in which the same provider refers and performs an imaging service, and therefore would not be addressed by CMS's multiple procedure payment reduction policy. As noted in our report, this payment reduction would affect about 10 percent of advanced imaging services referred by self-referring providers. In addition, while CMS raised questions about whether implementing our recommendation would violate Medicare's prohibition on paying a differential by physician specialty for the same service, the agency did not indicate how it would do so as of October 2016. We continue to believe that CMS should determine and implement a payment reduction to recognize efficiencies for advanced imaging services referred and performed by the same provider even though, as of October 2016, the agency has no plans to take further action.
    Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should determine and implement an approach to ensure the appropriateness of advanced imaging services referred by self-referring providers.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: HHS noted that it would consider this recommendation. The Secretary of HHS has the authority to establish a program to promote the use of appropriate use criteria - criteria that are evidenced-based (to the extent feasible) and that assist professionals to make the most appropriate treatment decisions for a specified clinical condition - for advanced imaging services under the Protecting Access to Medicare Act of 2014. CMS has begun developing its appropriate use criteria program (e.g., in November 2015, CMS established criteria to identify Qualified Provider Led Entities that are responsible for developing appropriate use criteria and has since selected Qualified Provider Led Entities), but full implementation of the program will not occur until at least January 1, 2018. If it - and the subsequent prior authorization program that incorporates appropriate use criteria - are implemented broadly enough (i.e., they ensure the appropriateness of advanced imaging services by all physicians, including those who self-refer), we could close the recommendation.
    Director: Kohn, Linda T
    Phone: (202)512-3000

    2 open recommendations
    Recommendation: As HHS implements its current and forthcoming efforts to make transparent price information available to consumers, HHS should determine the feasibility of making estimates of complete costs of health care services available to consumers through any of these efforts.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In May 2013, CMS released average inpatient hospital charge information for more than 3,000 hospitals that receive Medicare Inpatient Prospective Payment System payments for the 100 most frequently billed discharges using DRGs from FY2011 and corresponding average Medicare payments. Shortly thereafter CMS also released outpatient charges. In April 2014, CMS also released data on payments to physicians under Medicare part B. This represents an effort to provide price transparency, although these are not complete cost estimates according to our definition in this report. As of September 2015, we are awaiting an update from HHS on the status of this recommendation. We will update the status of this recommendation when we receive additional information.
    Recommendation: As HHS implements its current and forthcoming efforts to make transparent price information available to consumers, HHS should determine, as appropriate, the next steps for making estimates of complete costs of health care services available to consumers.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of September 2015, we are awaiting an update from HHS on the status of this recommendation. We will update the status of this recommendation when we receive additional information.
    Director: Cosgrove, James C
    Phone: (202)512-7029

    2 open recommendations
    Recommendation: To help ensure that Medicare beneficiaries have access to high-quality dialysis care, the Administrator of CMS should assess the extent to which the bundled payment for dialysis care will be sufficient to cover an efficient dialysis organization's costs to provide such care when the bundled payment expands to cover oral-only ESRD drugs. The Administrator should conduct this assessment before implementing this expanded bundled payment.

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

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: In order to ensure effective monitoring of treatment of mineral and bone disorder, the Administrator of CMS should continue collecting data for quality measures related to this condition from sources such as the Elab Project until CROWNWeb is fully implemented and concerns about its data reliability have been adequately addressed.

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

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Farrell, Brenda S
    Phone: (202)512-3604

    1 open recommendations
    Recommendation: To better understand the extent to which deployed DOD civilian employees have access to needed medical care, as appropriate, the Secretary of Defense should direct the Combatant Commander of U.S. Central Command to clarify the level of care that deployed DOD civilian employees can expect in theater, including their eligibility for routine care.

    Agency: Department of Defense
    Status: Open

    Comments: As of September 2016, DOD has not taken all the steps to close this recommendation. A DOD official stated that, as a result of changes in theater, there have been changes in guidance regarding medical care and they believe the guidance is clear, but they have not received guidance from the Secretary of Defense directing them to clarify the level of care that deployed civilian employees can expect in theater, including their eligibility for routine care.
    Director: Iritani, Katherine M
    Phone: (202)512-3000

    1 open recommendations
    Recommendation: To improve the oversight of states' Medicaid supplemental payments, the Administrator of CMS should develop a strategy to identify all of the supplemental payment programs established in states' Medicaid plans and to review those programs that have not been subject to review under CMS's August 2003 initiative.

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

    Comments: As of July 2016, HHS officials reported that they have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Director: Steinwald, Alan Bruce
    Phone: (202)512-3000

    1 open recommendations
    Recommendation: Given the contribution of physicians to Medicare spending in total, the Administrator of CMS should develop a profiling system that identifies individual physicians with inefficient practice patterns and, seeking legislative changes as necessary, use the results to improve the efficiency of care financed by Medicare. The profiling system should include methods for measuring the impact of physician profiling on program spending and physician behavior.

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

    Comments: Physician feedback reporting was initiated under section 131(c) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), and was expanded by section 3003 of the Patient Protection and Affordable Care Act (PPACA). In addition, PPACA required the Department of Health and Human Services to coordinate the physician feedback program with a Value Modifier (VM) that will adjust fee-for-service physician payments for the relative quality and cost of care provided to beneficiaries. In 2012, CMS provided Quality and Resource Use Reports (QRUR) to large providers nationwide and physician-focused QRURs to groups with 25 or more eligible providers in 9 states; by 2014, CMS sent QRURs to all group practices and solo practitioners. Also, as required in the act, CMS applied the VM to select physicians in 2015, with all physicians being subject to VM by 2017. The Act requires the VM to be implemented in a budget neutral manner, meaning that any upward payment adjustments for high performance must balance the downward payment adjustments applied for poor performance. CMS officials said they develop and will continue to develop experience reports related to each year's QRUR/VM cycle. In 2015, CMS used VM results for physicians in groups of 100 or more in public engagement of stakeholders, encouraging them to report quality, because quality performance was the driver of the payment adjustments in 2015. CMS is working with its Center for Clinical Standards and Quality to think of how to better engage physicians and groups in reporting, to avoid the automatic downward adjustment. As the program gains experience, CMS will use the experience reports to examine the impact of QRURs and VM on the Medicare program. In order for this recommendation to be closed as implemented, CMS will need to expand its efforts to measure the impact of QRURs and VM on program spending and physician behavior.