Jennie Hitchcock, CCS-P, CMPE

Jennie L. Hitchcock is President of Compass International Resources, Inc. and is an advisor to healthcare organizations in the areas of regulatory compliance, risk management, mergers and acquisitions and operations. With extensive administrative and advisory roles, Jennie possesses a broad understanding of the industry as well real world experience. She holds a bachelor’s degree in organizational behavior and is currently pursuing her fellowship with the American College of Medical Practice Executives. Jennie is a Certified Medical Practice Executive (CMPE) and a Certified Coding Professional – Physician (CCS-P).

The Physician Compare website has been in existence since 2010, listing basic information such as names, addresses and gender about physicians and other health professionals (e.g. nurse practitioners and physician assistants). It’s no coincidence that, also in 2010, the Centers for Medicare & Medicaid Services (CMS) started providing financial incentives for physicians to provide data about their clinical activities, electronic record usage, and patient satisfaction. These two initiatives are now coming together in the form of public reporting of self-reported quality and other data about medical groups and physicians.

On June 16, 2016, MLN Connects held the first-ever national provider call on the topic. The call was just under 90 minutes in length, with over an hour devoted to questions and answers from medical practices across the country. At the end of the call there were as many outstanding questions as answers, and the audience was repeatedly encouraged to provide comments on the issues still in rulemaking. The deadline for public comments is June 27, 2016 (go online to https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-Feedback.html to read the proposed rules and comment).

Here are top three things I believe that medical practices should know about Physician Compare at this point:

    1.   If you don’t tell your own story about the quality of your care, CMS is going to tell it for you. Medical practices have a brief window of time each year in which they can review their reported quality data and make corrections before it is published on Physician Compare (it was the month of October in 2015; we encouraged practices to review their data here). This annual review process is established per regulations and is set for the next two years. During the question-and-answer period of the national call, a practice administrator asked whether CMS could provide the PQRS Feedback Report on a quarterly basis instead of annually.

    “How do we know where the heck we are?” she asked. The caller was advised to comment on the proposed rule in hopes of influencing this issue for future years. There is no doubt that more frequent feedback would be helpful for medical practices, but how will they know whether the feedback data is correct without tracking their own data internally? It’s important for medical practices to be able to tell their own story about their clinical quality and to back that story up with their own records. Practices that are not prepared to do this will relinquish control of their quality reputation to CMS (and third-party payors) as public reporting becomes more prevalent.

    2.   You have six months to prepare for “competitive ranking.” The current data on the Physician Compare website is based on metrics reported by medical practices in 2014. Only 20 measures were selected for public reporting that year, so many practices that reported quality data have no specific results showing on the website this year (although the website is supposed to give them credit for reporting, one caller said that her practice reported, but it was not indicated on the website). For those practices with publicly reported measure data, their success rate in the completing the measure is represented on a five-star scale, with each star representing 20 percent. The presenters said that the 2015 data will be publicly reported in “late 2016,” and it’s not clear which measures will be included, but all of the PQRS measures are eligible. By “late 2017,” the plan is that 2016 data will be reported (the data that practices are reporting this year), and a benchmark will have been established for each quality measure reported. This will be the basis for competitive ranking. The “ABC methodology” has been chosen to establish the benchmark and drive the ranking system. It was described on the national provider call as follows:

            •    Featuring a well-tested, data-driven methodology;

            •    Establishes top performers; and

            •    Provides a point of comparison.

    The problem is that the presenters on the national provider call could not clearly explain the formula. When one practice asked for an explanation, the presenter finally admitted that it was hard to explain the formula “without a white board.” The bottom line here is that top-performing medical practices will be identified by a complex statistical formula, and the government intends for that subset to get the five-star rating. The presenters stated that the intent is for “the difference between a five-star rating and four-star rating to (be) statistically significant.” It’s also reasonable to expect that these ratings will be tied to payment differentials under the Merit-Based Incentive Payment System (MIPS) program.

    What is a practice to do? First, understand that the quality ratings are not an end in and of themselves; they are a means to an end that is expected to create value for consumers. Whether the measures actually result in value remains to be seen, but clearly, medical practices that want to protect their reputations and garner the highest fee-for-service reimbursement must focus on performing as well as they possibly can on their quality measures. See point No. 1: track your data internally and work to improve your performance as measured by the quality metrics your practice has chosen. In essence, medical practices started competing against this to-be-determined benchmark in 2016 and have the remaining six months of the year to work on improving performance and the related data.

    3.   Basic information about your practice may be incorrect on the Physician Compare website. One practice called in with a concern that, while they had 13 practice locations over a wide geographic area, only their main office address was showing on the Physician Compare website. They were rightfully concerned about the confusion this would cause for existing and potential patients. The information on the Physician Compare website is based on the Provider Enrollment, Chain, and Ownership System (PECOS) framework, and only those health professionals approved in the PECOS system will be listed on the website. There were follow-up remarks about the difficulties that the medical practice community has had with PECOS and the frustration with the PECOS process overall. However difficult that may be, though, it will be more and more important for medical practices to grind through the process of ensuring that their information is correct.

Many large, sophisticated health systems and medical groups have been working on their quality data for many years in preparation for these developments. Small and medium-sized medical groups are now struggling to catch up and compete. These organizations typically own basic electronic health records and practice management systems. The basic PQRS and diagnosis coding being provided to CMS by these very practices is the data that these smaller organizations must begin to use in order to thrive – and perhaps simply to survive.

There was some discussion by one caller about avoidance strategies, e.g. solo physicians planning to change their tax identification numbers frequently to avoid reporting (the government never reports first-year data). To this, the presenters said simply that the consumers will draw their own conclusions about the absence of data. With organizations like Consumer Reports on the job, these strategies seem likely to backfire.

About the Author

Jennie L. Hitchcock is an advisor to healthcare organizations in the areas of regulatory compliance, clinical documentation and coding, risk management, mergers and acquisitions, and operations. With extensive administrative and advisory experience, Jennie possesses a broad understanding of the healthcare industry as well as real-world experience. She holds a bachelor’s degree in organizational behavior and is currently pursuing her fellowship with the American College of Medical Practice Executives. Jennie is a Certified Medical Practice Executive (CMPE) and a Certified Coding Professional – Physician (CCS-P). She serves as president of Compass International Resources, Inc., which provides staffing services in the government sector and consulting services in the healthcare sector.

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j hitchcockA common definition of “value” in healthcare is the delivery of the right care at the right time and in the right setting. But what is “right”? That depends on who you ask. The conversation about this topic among providers long has been fraught with frustration over the variation in quality measures across different payors. For example, even seemingly straightforward measures related to diabetes can be confusing. In my work with a physician organization seeking to earn quality recognition via the NCQA Diabetes Recognition Program (DRP), I quickly learned that providers often experienced consternation over the validity of the measures and variation in measures. This conversation distracted from the one that needed to be happening: actually making sure, and being able to objectively demonstrate, that diabetics got the basic elements of care that are widely agreed upon as necessary (e.g. regular foot exams).

Another issue for providers involves which of the measures should be required for reporting. The Centers for Medicare & Medicaid Services (CMS) announcement of an effort to standardize measure sets along specialty lines for Medicare and commercial payors featured an acknowledgement that “it is difficult to have actionable and useful information because physicians and other clinicians must currently report multiple quality measures to different entities. Measure requirements are often not aligned among payors, which has resulted in confusion and complexity for reporting providers.”

For PQRS, providers currently are allowed to choose which measures to report, leading to the inevitable choice of measures that are easiest to report, and not necessarily those that will have the most impact on quality in a given specialty. As the Medicare quality reporting program has evolved, this issue has been addressed via assignment of “measure stewards” and the requirement for “cross-cutting” measures; however, providers still have been free to, in essence, dodge reporting on measures that are difficult to collect and to prioritize performance measures over outcomes measures.

The public/private collaboration that resulted in the release of seven sets of specialty-focused measures will serve to narrow the focus of various specialties onto those measures that are likely most meaningful, given their clinical focus. This effort, coupled with a reduction in variation across payors, has a chance to continue moving the conversation from one focused on the problems with the reporting system to one focused on how to make operational improvement that reduces cost, improves quality, and reduces medical errors. The industry still has a long way to go, but in my book, the standardized measures are a step in the right direction.

About the Author

Jennie L. Hitchcock is president of Compass International Resources, Inc. and is an advisor to healthcare organizations in the areas of regulatory compliance, risk management, mergers, and acquisitions and operations. With her extensive experience in leadership, administrative, and advisory roles, Jennie possesses a broad understanding of the healthcare industry as well as real-world experience. She holds a bachelor’s degree in organizational behavior and is currently pursuing her fellowship with the American College of Medical Practice Executives. Jennie is a Certified Medical Practice Executive (CMPE) and a Certified Coding Professional – Physician (CCS-P).

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It’s easy to search for a hospital online at Medicare.gov and get general information such as the hospital’s location, whether Medicare assignment is accepted, and whether they offer emergency services. In addition, for many years now consumers have been able to access detailed data on the quality of the clinical services that hospitals deliver. Information about rates of infection and readmission, patient satisfaction, and even a hospital’s spending per Medicare beneficiary is all readily available.

When the Centers for Medicare & Medicaid Services (CMS) Physician Voluntary Reporting Program (PVRP) was launched over 10 years ago, I began discussing the inevitable progression of quality reporting with physicians and the importance of learning how to collect, report, and act on quality data. The voluntary program became an “initiative” (remember PQRI?) and then, in 2010, a “system” (PQRS). Bonuses turned into penalties, motivating physicians to report their quality data. Later this year, for the first time, some of that data will be made easily accessible to the public as it relates to some providers. The data will be published on the Physician Compare website, which up to this point has contained only general information about individual providers, such as address and board certification status.

The basis for the reported quality scores on Physician Compare will be the 2014 PQRS data that CMS has on file for each provider. Physicians and other healthcare professionals have a short window during which they can get a preview of their data before it is published for all to see. The preview period begins on Oct. 5, 2015 and ends on Nov. 6, 2015, which coincides closely with the time period during which CMS will conduct an “informal” review of PQRS data (that period ends Nov. 9, 2015). This informal review process will provide one last chance to identify potential mistakes and ask for corrections before the data is released.

The first step is for the provider (or their representative) to obtain the 2014 PQRS Feedback Report from the CMS quality reporting portal. If the report is negative and the provider has reason to believe the data is incorrect, it can request the informal review. This is the only opportunity for a provider to ask for consideration of changes, and all decisions will be final.

The same opportunity was available last year for providers subject to a 0.5-percent payment reduction that went into effect – some thought a mistake had been made by CMS in compiling their data. I talked to a number of physicians, particularly those in small practices, who considered this payment reduction immaterial compared to the administrative burden of reporting the PQRS data. These providers may be tempted to view the upcoming 2-percent reduction in the same light, with some unaware that the ramifications may include a negative public perception of their quality of services. Not only is the financial penalty higher for providers who choose not to report or who do not report sufficiently, their reputation may be at stake as well. Even those that have reported and avoided the penalty may be surprised by the results and miss the chance to correct any errors. This trend toward public reporting of individual provider data is sure to continue. Earlier this year CMS published a 10-page document outlining its strategic vision for physician quality reporting.

“This Physician Quality Reporting Programs Strategic Vision (or “Strategic Vision”) describes how CMS will use the lever of ;measuring and publicly reporting providers’ quality performance’ to advance the CMS Quality Strategy goals and objectives,” the document read, “and facilitate the provision of care that is person-centered and brings the kind of quality, access, and coordination that produces results.”

For better or worse, the practice of collecting and disseminating quality data on individual providers will be an ongoing priority for CMS, and private payors likely will follow suit. Taking the time to preview the data and ask for a review should be routine for all providers, starting this year.

CMS has issued a fact sheet outlining the details related to how to request the PQRS informal review, available online at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014_PQRS_IR_2016_Pay_Adj_Made_Simple.pdf. The agency also issued a fact sheet on how to preview the data to be published on Physician Compare, accessible at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/physician-compare-initiative/Downloads/PQIP-Quick-Guide-2014-.pdf.

About the Author

Jennie L. Hitchcock is the director of operations for the Department of Coding and Regulatory Audits at DoctorsManagement. Jennie has dedicated her career to serving physician organizations and excels in executive leadership and regulatory compliance. With extensive experience in administrative and advisory roles, Jennie possesses a broad understanding of the industry as well as an in-depth knowledge of the inner workings of healthcare systems. She holds a bachelor’s degree in organizational behavior and is currently pursuing her fellowship with the Medical Group Management Association. Jennie is a Certified Medical Practice Executive (CMPE) and a Certified Coding Professional – Physician (CCS-P).

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