Coming This December: Santa’s Naughty & Nice List for Eligible Providers

In approximately two months all 2015 quality data reported by any practitioner (collected by any mechanism) will be made public by the Centers for Medicare & Medicaid Services (CMS). If you’re a podiatrist, wound care provider, or hyperbaric medicine practitioner who bills Medicare patients and submitted data to the Physician Quality Reporting System (PQRS) within the specified timeframe, your quality performance data will be publicly visible on Medicare’s Physician Compare website (www.medicare.gov/physiciancompare/search.html). In preparation for this reality, I’m providing an overview of what could amount to a rather confusing “naughty and nice” list. CMS was required by the Affordable Care Act to establish Physician Compare. Since launching the website in 2010, CMS has been trying to include more useful information about physicians and other healthcare professionals who participate in Medicare within the site. Medicare officials believe making performance data public can improve care for beneficiaries, and they see this as a means for providers to demonstrate their commitment to quality care. As a result, the two main goals for Physician Compare are to: 1) encourage consumers to make more informed choices based on quality performance data, and 2) incentivize physicians to maximize their performance in quality programs. Currently, the site offers information on providers who participate in Medicare, including one’s name, specialty, address, board certification(s), education, residence, hospital affiliation, gender, and whether the provider reported quality measures or uses an electronic health record. To be listed on the site, a healthcare professional must be in an “approved” status in the Provider Enrollment, Chain and Ownership System for Medicare; provide at least one practice location address; have at least one specialty noted; and have submitted a Medicare fee-for-service claim within the last six months. It’s possible to search for healthcare professionals and practices within a certain location by name, medical condition, or specialty. That means it’s not possible to search for a physician involved in wound care, because it’s not a specialty. All providers should go to Physician Compare to check their data. If there are any corrections to be made, contact the support team at physiciancompare@westat.com 

Performance Data & Public Reporting

Physician Compare has gradually been adding data from PQRS, beginning with group practices in 2014. The website has always seemed focused on primary care, but that’s also how PQRS tends to work. Data reported in 2014 were on general health (eg, flu shot, pneumonia vaccination), cancer screening, heart disease, diabetes, and patient safety. It’s important to remember the audience for Physician Compare is the consumer. Additional quality data files are available for download and may be used by payers or other entities. Any PQRS measure may be reported, but CMS officials decide exactly which measures to report based on published public reporting standards and the federal rulemaking process. Measures must pass various tests of statistical validity, and there is a 20-patient minimum threshold for each measure. Measures that meet these criteria are turned over to a Physician Compare support team that develops plain-language titles and descriptions for them. Then, CMS conducts consumer testing of the measure. Consumer testing assesses whether consumers understand the information that the measures are supposed to convey and whether the data would help consumers choose healthcare providers. Interestingly, if a measure meets all of the public reporting standards except the requirement that it resonates with consumers, the measure data may be added to the downloadable database, but will not be included on the website for public viewing. I’m not sure if this point can be over-emphasized. That’s an interesting thing to ponder if you’re a podiatrist or wound care clinician who succeeded with PQRS thanks to the diabetes measure group (for example), which has no direct relevance to wound care and little relevance to podiatry other than the foot assessment of patients living with diabetes. 

Achievable Benchmark of Care 

A benchmark helps consumers understand the context for measure performance rate by providing a point of comparison to other clinicians. Item-level measures must have a benchmark “passing rate.” These rates are created using the Achievable Benchmark of Care (ABC) methodology. CMS officials rank healthcare professionals from highest to lowest performance score for a specific measure, then select the subset of top healthcare professionals representing at least 10% of the eligible patient population for the measure, and then calculate the number of patients receiving the intervention or desired level of care for that measure. The number of patients is then divided by the total patient population for the top doctors to calculate the benchmark — meaning the benchmark is specific to each measure. The earliest benchmark will be reported in late 2017. CMS will take these benchmarks and devise a way to create “Five Star Ratings” for providers based on these benchmarks.

Impact on Wound Care Practitioners

This is yet another reason wound care clinicians should consider moving away from standard PQRS measures or the diabetes measure group, which is being reported by endocrinologists and internists, and towards measures that are relevant to their practice. The ABC method means: 1) you are graded on a “curve” based on the other providers reporting that measure, and 2) you are going to end up with a star rating based on the measures you are reporting. So, wound care clinicians or podiatrists could end up being listed as (for example) a “one-star” provider simply because they are performing on the low end of the spectrum in a set of quality measures that’s not relevant to their practice and that they reported just to “get through PQRS” to avoid a financial penalty. This is akin to measuring how well a fish can ride a bicycle. A wound care practitioner may score poorly at blood pressure control and body mass index follow up in comparison to an endocrinologist whose job it is to manage these things, despite being a fantastic wound care practitioner. That’s why reporting wound care-specific quality measures like those offered by the U.S. Wound Registry (USWR) are a better alternative in the long run. At least wound care practitioners can report measures relevant to their practice. By late 2017, Qualified Clinical Data Registry measures will also be reporting item benchmarks. If you want to see a list of forward-thinking eligible wound care providers, check out those clinicians who reported USWR wound care quality measures in December. Their quality data will be posted on the USWR website (www.uswoundregistry.com). It won’t just be patients who are looking at those quality data to select the best wound care practitioner. Private payers will use it to decide where to send patients, which could end up being very nice for those wound care clinicians. There’s another advantage to reporting wound care measures through the USWR. Wound care isn’t a recognized medical specialty and, since the American Board of Medical Specialties won’t grant any new primary specialties, the only way for wound care practitioners to be identified as “wound care practitioners” is to report the same quality measures. If wound care practitioners were to all report the USWR quality measures, then suddenly we will have done the next best thing to creating a specialty — we will have created a specialty measure group for wound care. That would be what I’d call the “nice list” for wound care practitioners. 

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.