CMS Quality Public Reporting

The 2010 Patient Protection Affordable Care Act (PPACA) required that the Centers for Medicare & Medicaid Services (CMS) make information on quality and patient experience measures publicly available. CMS, in turn, created the Hospital Compare and Physician Compare website, which are available to the public and allow consumers to find and choose hospitals as well as individual physicians and other healthcare professionals enrolled in Medicare. The information on Physician Compare comes primarily from the Provider, Enrollment, Chain, and Ownership System (PECOS), which is checked against Medicare claims data. Unlike the Hospital Compare website, which reports information at the hospital level, the Physician Compare website includes public information on individual practitioners and group practices (Click on the table thumbnail image below to view full size.).

CMS Program	Type of Reporting	Individual Data	Group Data
Hospital Compare	Public website	No information is provided on individual healthcare professionals employed by hospitals	Timely and effective care Readmissions, complications, and deaths Use of medical imaging Patient experiences Number of Medicare patients Payment and value of care
Physician Compare	Public website and database   NOTE: Information is published in approximately one calendar year after it is reported.	Practice location(s) Indicators for participation in CMS quality programs Board certification Gender Medical school education & residency Primary and secondary specialties Group and hospital affiliations	Practice location(s) Indicators for participation in CMS quality programs Affiliated healthcare professionals (individuals who work with the group) Clinical quality of care data/performance for entire group (not for individual healthcare   professionals)

CMS=Centers for Medicare & Medicaid Services.
 
CMS first published quality data on the Physician Compare site in February 2014 on a subset of 2012 Physician Quality Reporting System (PQRS) measures, which consisted of Group Practice Reporting Option (GPRO) Diabetes Mellitus and Coronary Artery Disease measures for the 66 group practices and 141 Accountable Care Organizations that successfully reported via the GPRO web interface. In late 2014, CMS publicly reported a second subset of data on Physician Compare, reflecting data collected in 2013. Since then, CMS has continued to expand the reporting of quality information every year through its rulemaking process.

The 2010 PPACA also extended and enhanced the Value-Based Payment Modifier Program, which is used to adjust Medicare Physician Fee Schedule (PFS) payments based on the quality and cost of care delivered to the Medicare beneficiaries attributed to providers. One of the main goals of the VM program is to give providers information about the quality and cost of care furnished to their Fee-for-Service Medicare beneficiaries. As such, confidential feedback reports, called Quality and Resource Use Reports (QRURs), are disseminated privately to solo practitioners and groups of practitioners, as identified by their taxpayer identification numbers (TINs). 
 
The table below explains what type of information is contained in the reports at the individual practitioner and TIN levels, which can also be accessed by all of the eligible professionals within the same TIN.

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Special Note: As of the PQRS 2016 reporting year, the VM will officially apply to all CRNAs who work as solo practitioners or as part of a group practice, which will affect the 2018 payment adjustment. For more information about CRNAs and VM please visit our updated VM Quick FAQs page.
 

Physician Compare only publishes information on individual eligible professionals (EPs) and group practices who satisfactorily report under the Physician Quality Reporting System (PQRS) and Group Practice Reporting Option (GPRO), as well as those who successfully participate in the Electronic Prescribing (eRx) Incentive, Electronic Health Record (EHR)/Meaningful Use Incentive, PQRS Maintenance of Certification incentive, and Million Hearts^® programs. 

This information (i.e., ability to satisfactorily report) is indicated by a green check mark on the individual or group’s profile page (see screengrab image on the right). Physician Compare will begin  publishing performance rates on PQRS measures for individual EPs and group practices in late 2015. 
 
In addition to profile information, Physician Compare currently includes quality of care performance scores for a small number of group practices and Accountable Care Organizations (ACOs).

All measures available for public reporting on Physician Compare are decided via rulemaking; however, not all measures available are publicly reported on the Physician Compare website. CMS decides which measures to publicly report based on their public reporting standards of reliability, validity, accuracy, and consumer relevance. 
 
The CMS infographic below further explains how they select measures for public reporting on Physician Compare: (Click on thumbnail to enlarge)

Individual EPs who reported via claims on any of the selected subset of PQRS measures in 2014 (see table) had their data made available for public reporting on Physician Compare in late 2015. 

Table. PQRS Measures Reported in 2014 That Will Have Data Publicly Reported in Late 2015

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According to the 2014 Physician Fee Schedule (PFS) Final Rule, all Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) measures—collected during the 2014 reporting year via the Web Interface—will be made available for public reporting for groups of 25 or more eligible professionals (EPs). Patient experience data such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for PQRS measures will also be made available for public reporting for groups of 25 or more.

Quality measures performance rates are displayed as stars and a percent. Each star represents 20% and stars are filled based on the performance score. For example, a 90% performance score on “Controlling blood pressure in patients with diabetes” is displayed in the image below as four and one-half stars followed by 90%



If you or your group practice did not report any of the above individual-level measures (via claims, registry, or EHR) or GPRO Web Interface measures in 2014, then you should not have measure data currently publicly reported on Physician Compare.  

Special Note: 2014 registry data was not publicly reported on Physician Compare in 2015 because these data did not meet the public reporting standards. Furthermore, 2014 EHR data were not publicly reported on Physician Compare in 2015 because CMS was unable to determine the accuracy of these data.

Starting in 2016, individual-level Quality Clinical Data Registry (QCDR) measures, which include 2015 PQRS and non-PQRS data, will be available for public reporting on Physician Compare unless the QCDR chooses to publicly report measures on its own website. In 2017, both individual and group-level QCDR measures will be available for public reporting. CRNAs should be aware that participation in a QCDR may result in public reporting of performance rates for both PQRS and non-PQRS measures.



Quality measures performance rates are displayed as stars and a percent.  Each star represents 20% and stars are filled based on the performance score.  For example, a 90% performance score on “Controlling blood pressure in patients with diabetes” is displayed in the image below as four and one-half stars followed by 90%


 
Beginning October 12, 2016, individual EPs and group practices with measure data will have a 30-day preview period to view their data as it will appear on Physician Compare.  You can access the secured preview site through the PQRS portal-Provider Quality Information Portal (PQIP) using an EIDM account. If you have any questions, please contact PhysicianCompare@Westat.com or visit the Physician Compare Initiative page. For additional assistance with PQIP, contact the QualityNet Help Desk at 866-288-8912 or qnetsupport@hcqis.org.
 
Per the 2016 PFS Final Rule, CMS is also targeting to publicly report an item-level benchmark using the Achievable Benchmark of Care or “ABC™” methodology. The Physician Compare benchmark will be publicly reported in late 2017 where it will serve as the basis of a rating system. According to CMS, this benchmark will allow consumers a better way to evaluate the information published on Physician Compare by providing context for performance scores and a means to compare rates between groups and between individuals. The benchmark only applies to PQRS data. For non-PQRS measures, QCDRs are free to develop their own benchmark methodology and benchmark rates and submit this information to Physician Compare for public reporting consideration when and where appropriate.
 
For more information and a step-by-step demonstration on how the benchmark will be applied to a measure, view the
Public Reporting Sessions Reference from the CMS website.