Public Reporting on Physician Compare: What You Need to Know – Webinar Recording


Alesia: Hello and welcome to
the public reporting on Physician
Compare webinar. I’m Alesia Hovatter, Health Policy
Analyst in the Division of Electronic and Clinician Quality
in the Quality Measurement and Value-Based Incentives Group,
otherwise known as QMVIG. in the Center for
Clinical Standards and Quality at the Centers for
Medicare and Medicaid services, also known as CMS. QMVIG is responsible for
evaluating and supporting the implementation of
quality measure programs. These programs aim to assess
health care quality in a broad range of settings, such as
hospitals, clinicians’ offices, nursing homes, home
health agencies and dialysis facilities. Our group actively works with
many stakeholders to promote widespread participation in the
quality measurement, development and
consensus process. I’ll be joined today by
two members of the Physician Compare
support team, Lisa Lentz and
Allison Newsom. Next slide, please.
This is our disclaimer slide. I’ll let you read over it
at your convenience. Now, we’re on
slide three, which is acronyms in
this presentation. This is just a helpful
guide for acronyms that
we’ll be using today. Next slide,
please. We’re on slide
number four now. The purpose of today’s
session is to provide a brief overview of
Physician Compare, share information about
public reporting of the merit-based incentive payment
system, known as MIPS, and the Alternative Payment Model, known
as APMs, and discuss some next steps for Physician Compare and
public reporting. During the last half-hour
of the webinar, we will open the lines and
members of our team will answer
questions. Lisa Lentz: Great, thank you Alesia and good
afternoon everyone. I’ll now provide an overview
of Physician Compare. Before I do,
though, I want to acknowledge that we
have a diverse audience on the line today in terms of their
familiarity with Physician Compare. For that reason I will
do my best to cover this in such a way that works for everyone,
whether you’re joining us for the first time and are new to
Physician Compare or whether you’re very familiar
with the site already. If you do have
questions, you will have a chance
to ask them at the end of the
presentation. CMS established
Physician Compare as required by Section 10331 of
the Patient Protection and Affordable Care
Act or ACA. As a result of ACA
the site launched on December
30th, 2010. The Medicare and CHIP
Reauthorization Act, or MACRA, passed in
2015 and provided additional direction
for the website. Physician Compare
is a website that lists information about
clinicians, groups and Accountable Care
Organizations or ACOs. As you’ll see here
on the slides, Physician Compare
has a dual purpose. It helps people with Medicare
make informed healthcare decisions. It also
incentivizes clinicians and groups to maximize
their performance. One of the frequently
asked questions we get about Physician Compare is
what are the criteria to be listed on the website? To be listed on
Physician Compare, both clinicians and groups must
be approved in the Provider Enrollment, Chain, and Ownership
System, PECOS, which is the sole verified source of Medicare
provider information. They also need to have at
least one practice location, and in the last six months, have
submitted a Medicare fee for service claims or be newly
enrolled in PECOS. Additionally, clinicians
must have at least one specialty listed in
PECOS and groups must have a legal business name and
at least two active Medicare clinicians reassign their
benefits to the group’s tax ID number
or TIN. We did also want to note
that for ACOs to be included on the site, they must have performance
information from 2016. On this slide, we’ll see here is
the general information that is on Physician Compare
for clinicians and groups. For both clinicians and
groups, we list name, address, phone numbers, medical
specialties, Medicare assignment status, that is, whether or not
a clinician accepts the Medicare-approved
payment amount. Then, for clinicians, we also include board
certification, education, residency, gender, group, and
hospital affiliation. For groups, we also have information about
affiliated clinicians or clinicians that practice as
a part of that group. The affiliated clinicians
determine the groups’ specialties and ACO
affiliation. For ACOs we have a little
bit more basic information than we do for clinicians
and groups, as we are able to link directly to the
ACO web pages. Much of the general information
we post on Physician Compare comes from
PECOS, names, locations, phone numbers, group
affiliation, specialties, Medicare assignment status,
education, and gender. We also use claims data to
verify information, such as practice location and
group affiliation, that we received from
PECOS as well as using claims data for
hospital affiliation. We also currently have
information available from four boards listed on
the website. Those boards include
the American Board of Medical Specialties,
the American Osteopathic Association, American Board of
Optometry, and the American Board of Wound
Medicine and Surgery. Because we use a lot of information from PECOS to
populate Physician Compare, it’s very important to keep that
information in PECOS up to date. It could take up to two to four
months for changes to appear on Physician Compare after they
are updated in PECOS. We invite you to visit the
Physician Compare Initiative page to learn more about
which fields in PECOS are driven for
website populations. If you have more information or
any specific questions about updating your information,
please don’t hesitate to contact us at
[email protected] Also, just to give more context
about the public reporting of performance information on
Physician Compare, we wanted to show this roadmap. Beginning in February
2014, we publicly reported a subset of 2012 group
PQRS, or physician quality reporting system measures, as
well as some ACO measures. Since then, every December, we
publicly report the previous year’s data as part of our
continued phased approach to public reporting. For
example, in December 2015, we publicly reported 2014 data
for groups and ACOs. In addition, this is also
the first time we reported clinician
level data. In 2016 we reported program
information submitted through qualified clinical data
registries, or QCDRs, for the
first time as well. This past December we
added 2016 performance information and this was also
our first time reporting measure level, star ratings, for a
subset of the 2016 group PQRS measures. Looking ahead in late
2018, we will add 2017 Quality Payment Program
information to the site. We’ll discuss this
in more detail as we go through
the rest of the presentation. At this time I’d like to pass
the presentation over to Allison Newsom who will walk
through the public reporting with the Quality
Payment Program. Allison Newsom:
Thanks so much, Lisa. The Medicare and CHIP
Reauthorization Act, or MACRA, and the creation of the Quality
Payment Program provided some additional direction for public
reporting on Physician Compare. In this next section, I’ll discuss information on
how the Quality Payment Program may be publicly reported on
Physician Compare. First, some background about the
Quality Payment Program. Under the Quality Payment
Program, there are two tracks in which clinicians
may participate. The first is the merit-based incentive
payment system or MIPS. The second is called
Advanced Alternative Payment Models or
Advanced APMs. Certain clinician types are
eligible to participate in the Quality Payment
Program. There are also
some additional requirements that clinicians
must meet in order to be able to participate. There’s a link on this slide
to learn more about clinicians that were eligible
to participate in 2017. If you have any questions about
this, we recommend that you reach out to the Quality
Payment Program directly. Their contact information is
included at the end of this
presentation. Year one of the Quality
Payment Program data are the 2017 performance
period data. Those data are
available for public reporting on Physician Compare
starting in late 2018. All data that goes on Physician
Compare must meet the established public reporting
requirements to be included on the site unless otherwise
required by statute. Data must be statistically
valid, reliable, and accurate, and it must be comparable
across submission mechanisms and meet the
minimum reliability threshold. Additionally, to be included
on the public facing profile pages, data must prove
to resonate with patients and caregivers as shown
through user testing. I just want to point out
that first-year measures will not be publicly reported on
Physician Compare in 2018. Additionally, voluntary data
reported in 2017 will not be posted on the site
for 2018. When I say
voluntary data I’m referring to data reported
by clinicians who were not considered to be eligible
clinicians for 2017. This slide shows the 2017
MIPS information that are technically available for
public reporting for groups and clinicians
later this year. The four categories are quality,
cost, Improvement Activities, and Advancing Care Information,
which for year two is now known as promoting
interoperability. In the next few
slides, we’ll share more information
about how these categories may be publicly reported. I also wanted to call out
that, although these data are considered available for
public reporting, not all data will be publicly reported
on the site this year. In addition to the four
categories, we’ll also have
information about clinicians’ performance category
scores and their final scores, as well as we will be publicly
reporting aggregate MIPS information, which will include
the range of final scores for all MIPS eligible clinicians and
the range of performance for all MIPS eligible clinicians within
each performance category. For the quality category, we’re
tracking to all collection types being available for
public reporting. Only one
collection type per measure will be
made public at this time. This is to meet our public
reporting standard that data must be comparable. We want to be sure that
variations in score are due to actual variations in
performance, not due to the collection types or maybe there
are some variations in the specifications for those. The following measure
types will not be publicly reported
in 2018. Again, we will not
be publicly reporting first-year measures
nor will we be publicly reporting non-proportional
measures, so continuous or ratio measures, or non risk-adjusted
outcome measures. For MIPS quality measures, we
expect to publicly report a subset of the 2017
data in late 2018. We’re tracking to
publicly reporting these measures as
star ratings. Measures that are
reported as star ratings must meet the established
public reporting standards, and then additionally
they must meet an additional level of reliability testing. The star rating
cutoff and the star ratings must
prove to be reliable. The image on this
slide is an example of how we are currently publicly
reporting the quality measures. You can see here that
we’ve got plain language measure title and a plain
language measure description, either written in a
way that is meant to be understandable and meaningful to
our main website users, which is Medicare
beneficiaries and caregivers. You also see an example of a
star rating for quality measure. This is just an example of
what the data may look like when it goes up on Physician
Compare later this year. We’re using the 2016
measures as an example. If you are interested
in learning more about the star ratings for MIPS
quality measures, we have a benchmark and star ratings fact
sheet that’s available on the Physician Compare
Initiative page. If you click this
link on the slides when you get them,
it will take you right there. I highly recommend that
you look at that. In addition to the
MIPS quality measures, we’re also tracking to
publicly reporting QCDR and CAHPS for
MIPS measures. We wont be publicly
reporting those as star ratings at this time.
For QCDR measures, we’re reporting them as a
percent performance score. For the CAHPS for
MIPS measures, we’ll be reporting them as
a top box score. This is the Agency
for Healthcare Research and Quality, or AHRQ’s,
suggested method for publicly reporting
CAHPS scores. We’ve also seen, from
previous user testing, that this way of publicly
reporting the measures is well understood by consumers.
Again, on this slide, you’re seeing an example of what the
scores would look like on Physician Compare
using the 2016 data. We expect the 2017
data going up later this year to look
similar to this. The next category under MIPS
is Improvement Activities. At this time, we are not
tracking to publicly reporting any Improvement Activities later
this year because all of the 2017 performance year
Improvement Activities are considered to be first-year
activities and therefore not available for
public reporting. In future years,
all improvement activities are available for
public reporting and we’re evaluating how those will be
publicly reported on the site. Next up is Advancing Care
Information, which I mentioned is known as promoting
interoperability for year two. Advancing Care Information may
be publicly reported on the site in up to three
different ways, the first of which is
that clinician and group profile pages will have
an indicator for satisfactory and high ACI performance
as technically feasible. ACI attestations may be reported on clinician and group
profile pages using check marks and plain language
descriptions. ACI measures are
available for public reporting if they
meet the established public reporting
standards. Similar to the other categories,
first-year ACI measures and attestations are not
available for public reporting. We’re not targeting to
publicly report cost data in 2018 as it’s not being used
for scoring in the first year. The Physician Compare support
team is continuing to evaluate ways to publicly report this
performance category in future years and will be sure to
share more information with About this with you
as it’s available. In addition to publicly
reporting information and profile pages, we’re also
tracking to reporting performance information in the
downloadable database. Performance
information that meets all statistical public
reporting standards but does not resonate with website users will
be added to the Physician Compare downloadable database.
Our reasoning behind this is that the profile pages are
intended for use by Medicare beneficiaries and
their caregivers. Meanwhile, the downloadable
database has a primary audience of people like
researchers clinicians or others who are interested in
digging more into the data, and so we have some
additional information available in that
downloadable database. Also, MACRA requires that we publicly report
utilization data, so currently we’re publicly reporting a
subset of the 2015 utilization data in the Physician Compare
downloadable database. When we update the downloadable
database to include the 2017 performance data, we’ll also
be updating it to include a subset of the 2016
utilization data, which is what’s most
recently available at that time. Moving on from
the four MIPS categories, we’re now shifting gears to
talk about Alternative Payment Models or APMs. Beginning in late 2018, Physician Compare is targeting
to publicly report information about 2017 APM participation
as technically feasible. Clinician and group profile
pages will have an indicator that they participated in the
Quality Payment Program. We’ll also link clinicians
and groups to APM profile pages for selected
advanced APMs and Shared Savings Program or SSP
Track One ACOs. At this time we’re still
assessing which APM performance information meets our
public reporting criteria and will be publicly
reported later this year. That was a quick overview
of how we will be publicly reporting the 2017 Quality
Payment Program performance information on
Physician Compare. Now, I’d like to talk about
what you can expect in the coming
months. In fall of 2018 we’ll be
previewing the 2017 performance information during our Physician
Compare preview period. The preview period is intended
to give clinicians and groups a chance to see what
their performance data will look like before it’s
publicly reported on Physician Compare profile
pages later this year and in the downloadable database when it’s
made publicly available. During this fall, we’ll be hosting a
National Provider Call. At this time we’ll share more
information about the specific 2017 measures
targeted for preview and public reporting
in late 2018. We’ll share an official
date for the NPC as it is
available. Again, during this
National Provider Call, this is when we’ll be
sharing materials about how to access the preview period as
well as detailed documentation about the specific measures and
attestations that will be available for preview and then for public
reporting later this year. The 2019 Medicare Quality
Payment Program Proposed Rule is currently out for
public comment. Because we’re in active
rule making, we’re unable to discuss the proposals
at this time. However, we do want
to encourage you to review the Proposed
Rule and submit public comment by September
10th 2018. You can use the
link on this slide to access
the Proposed Rule. As I’ve mentioned
multiple times throughout the presentation,
there’s a lot more coming for Physician Compare in
the next few months. We want to make sure that we
are staying engaged with you and are able to
share this information. One way to keep in
touch with us is to sign up to receive the
Physician Compare e-news. You can use the link on
this slide to do that. Another way is to continue to engage with us about the
future of Physician Compare. So If you’re an interested
clinician or a group representative and you want to
talk to us about the future of Physician Compare in one-on-
one or small group discussions, please contact us at
[email protected] com. We would love to
hear from you. That concludes
today’s presentation portion of the webinar. I ‘m now going to pass
things over to my colleague Laura to facilitate the
Question and Answer session. Laura: Thanks,
Allison. We are now going to stop
the recording of today’s presentation and begin
our Question and Answer session.

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