QRUR: Trick or Treat?

I continue to be amazed by how quickly this year is flying by. October will soon be behind us and we will begin thinking about Thanksgiving. Standing between us and November, however, is Halloween. Many of you will be passing out treats on Friday night and others will be shepherding excited children through local neighborhoods in search of those treats. This Friday evening will also see its share of tricks. In the spirit of Halloween, let’s return our attention to the Quality and Resource Use Report (QRUR), with the hope that you find this post more treat than trick.

 

Waldo spotted

Two weeks ago I walked through the path one might take to actually lay hands on the elusive QRUR. I have heard from some of you that that journey has been successful, and from others that the journey continues. If you have yet to obtain your practice’s QRUR, do not surrender! Your diligence will ultimately be rewarded. For those with the QRUR in hand, this overview from CMS is worth a look.

 

At a high level, the QRUR contains several items of interest:

1. The QRUR identifies your practice and some of the characteristics of the patients attributed to your practice for the physician value-based payment modifier (VM).
2. The report identifies your practice’s performance on the quality metrics within the (VM).
3. It also identifies your practice’s performance on the cost metrics within the VM.

Let’s examine each in turn.

 

Your practice

The first three exhibits in the QRUR reveal characteristics about your practice. Exhibits 1 and 2 are worth a look. Has the QRUR counted providers in your practice accurately? Exhibit 1 lets you know what your head count looks like in the eyes of CMS. Exhibit 2 provides some insights regarding the Medicare population attributed to your practice for the purposes of the VM. Pay close attention to this one as it defines how beneficiaries are being attributed to your practice. FAQ 5 in this very useful document from CMS clarifies how a Medicare beneficiary ends up in your practice’s bucket, so to speak. Finally, another table that provides insight into your practice, exhibit 6 defines the hospitals where beneficiaries attributed to your practice were hospitalized during 2013. Hospitalization is an important component of both the quality and cost composite indexes for the VM. Take a look at exhibit 6. Any surprises here?

 

Your quality

Insight into your practice’s performance with respect to the VM’s quality metrics begins with exhibit 4, and in the spirit of Halloween, let the tricks begin. Most of you will not have an exhibit 4. For 2013, the presence of the table in exhibit 4 requires that your practice submitted PQRS via GPRO last year or that you elected the “one and done” administrative claims option for PQRS in 2013. If you are missing exhibit 4, fear not, as there is additional information regarding quality within this report. Take exhibit 14 for example. The table in exhibit 14 should be very familiar to you. This is a roll up of your practice’s performance across the individual PQRS measures the providers in your practice reported in 2013. This is one of those tables you need to review very carefully. Notice the last column displays the benchmark rate. Think of this as the national average performance score for each of the PQRS measures the providers in your practice reported in 2013. Your practice’s performance is being compared to this national mean.

 

Next up in the quality domain is exhibit 5. Recall from our earlier review of the VM that quality is a composite of both the practice’s PQRS performance and the practice’s performance with respect to several hospitalization metrics. The table in exhibit 5 displays your practice’s performance with respect to those hospitalization metrics for the beneficiaries attributed to your practice. Note smaller practices will have many blanks in the later columns (standardized scores and “included in domain score”). This occurs when the practice has fewer than 20 eligible cases for a measure. CMS has determined when the numbers are that small, the scores are not accurate. The absence of data does not mean your practice is not scored for the QRUR. As they have done with other programs, in circumstances where they are unable to find a large enough data sample, CMS assumes you are an average performer and your practice is assigned a score equivalent to the national mean.

 

Before we move onto costs, let’s review one scarier nuance of the VM, which is more trick than treat. Historically many have viewed PQRS as a pay-for-reporting program. In other words, you are paid to simply report your quality data regardless of your actual performance on the individual quality measures. The VM is changing the nature of this game and exhibit 14 in your QRUR should serve to drive that point home. As you may recall from our previous post, in practices with 10 or more providers, at least half of the providers within the practice must successfully report PQRS in 2014. If this does not occur, CMS will park your practice in the highest penalty bucket within the 2016 VM matrix and impose an across-the-board 2% penalty on all Part B services billed by your practice in 2016. This subtle nuance adds substantial importance to successfully reporting PQRS in 2014 and in the years ahead.

 

Your costs

The balance of the remaining tables in the QRUR is related to your practice’s performance with respect to the VM’s cost metrics. Exhibit 8 yields the most value in my view. It breaks down the average total costs per capita for the patients attributed to your practice. As you may recall, costs with respect to the VM include all Medicare Part A and Part B costs for the Medicare beneficiaries attributed to your practice. FAQs 15 and 16 remind us that CMS standardizes the payment rates to strip out regional cost variations across the country (payment standardization) and they utilize the Hierarchical Condition Categories to risk-adjust patients in an attempt to avoid the “my patients are sicker” complaint one commonly hears when quality measures are discussed.

 

Exhibits 9 and 10 take a deeper dive into the costs attributed to your practice. The table in exhibit 9 provides an interesting breakdown in costs with respect to who delivered the service (your practice or someone outside your practice) and what types of services the beneficiaries attributed to your practice are consuming. Exhibit 10 takes this a step further and lets you zero in on areas where your practice may be taking it on the chin, as it were, with respect to the cost of care for those beneficiaries attributed to your practice.

 

Bonus section

Finally, I call your attention to one more item of interest to the practice of nephrology. FAQ 17 defines how CMS intends to level the playing field for medical subspecialties. Data used to determine the 2016 VM is being collected this year. Recognizing that the costs for beneficiaries are very likely to vary among the multiple medical specialties delivering that care, CMS has created a clever way to calculate their “specialty-adjusted cost” metric. After reading FAQ 17 more times than I care to admit, my take is that they are creating an average expected cost for nephrologists (and every other medical specialty for that matter). In my view this is wonderful news, a “treat” if you will, because the cost of care delivered to beneficiaries attributed to nephrology practices is almost certainly going to be higher than the average cost of care across the country, even after CMS goes through the standardization and risk adjustment gymnastics described above. You cannot see this figure in your 2013 QRUR; you will have to wait until the 2014 QRUR is available next year. I am sure you can hardly wait!

 

Trick or treat

Assuming your head is not spinning like a goblin on Halloween, I hope you have found this quick overview a benefit. The QRUR provides substantial insight into what I believe is a growing transition from our current health care economic model that rewards volume to one that rewards value. Value in this case is defined by quality as a function of cost. CMS has every intention of rewarding the efficient delivery of quality to Medicare beneficiaries. While we may not agree with their methodology, it is time to face the music. Take a close look at your QRUR as it will prepare you for the physician component of value-based purchasing. CMS is knocking on the door . . . trick or treat!