1.) Private Entities Selected a Range of Measures and Benchmarks to Assess Physician Group Performance, and Provided Feedback More than Once a Year

Private entities we reviewed provided feedback mostly to groups of  primary care physicians practicing within newer delivery models. Largely relying on claims data, health insurers spent from 4 to   6 months to produce the annual reports. Private Entities Focused Their Feedback Efforts on Groups of Primary Care Physicians Practicing within Newer Delivery Models

The private entities in our review had discretion in determining the  number and type of physicians to be included in their performance  reporting initiatives, and their feedback programs generally included only  physician groups participating in newer delivery models—medical homes  and ACOs—with which they contract. Entities further limited their physician feedback programs to groups  participating in medical homes with a sufficient number of attributed  enrollees to ensure the reliability of the reported measures. Private Entities Decided Which Measures to Report and Compared Physician Performance to Various Benchmarks, Leading to Differences in Report Content across Entities

Because each private entity in our study determined the number and  types of measures on which it evaluated physician performance, the  measures used in each feedback program differed. In addition to feedback on the total cost of care per enrollee, some reports  given to groups of primary care physicians contained information on the  cost of care provided by specialists in the entity’s network. Some  entities compared each physician group’s performance results to that of a  peer group (e.g., others in the entity’s network or others in the  collaborative’s state or region); some entities compared physician groups’  results to a pre-established target; and others gauged physician groups’  progress relative to their past performance. 6.) Private entities told us that physicians valued frequent feedback on their  performance so that they have time to make practice changes that may  result in better performance by the end of the measurement period. Interim reports typically  covered a 1-year performance period, and were commonly issued on a  rolling monthly, quarterly, or semiannual schedule. Each medical  group’s chosen method of quality data submission determined the quality  measures included in its report, to which CMS added health care costs  and certain outcomes measures. Therefore, the agency faces certain  challenges not faced by private entities as it has expanded its feedback  program to reach increasing numbers of physicians. Both CMS and private entities focused  on preventive care and management of specific diseases. Quality measures under this method pertain to care  coordination, disease management, and preventive services. Cost Measures

CMS included cost measures—several of which differed from the  measures private entities in our study reported to physicians—in all 2013  feedback reports (see fig. CMS Spent 9 Months to Produce the 2013 Feedback Reports, and Did Not Provide Interim Reports

CMS’s report generation process took longer than that of most private  entities in our study because it required more steps. Although they are not uniform in their approaches, the entities in  our study used their discretion to select a limited number of quality and  utilization/cost measures, calculated them using claims data, and used  them to assess performance against a variety of benchmarks. CMS’s use of a single nationwide benchmark to compare  performance on quality and cost ignores richer benchmarking  feedback that could benefit physicians. CMS’s  reliance on a national average as the sole benchmark precludes  providers from gauging their performance relative to their peers in the  same geographic area. Additionally, CMS disseminates feedback reports only once a year  (for example, September 2013). Recommendations for Executive Action

As CMS implements and refines its physician feedback and VM  programs, the Administrator of CMS should consider taking the following  two actions to help ensure physicians can best use the feedback to  improve their performance:
Develop performance benchmarks that compare physicians’  performance against additional benchmarks such as state or regional  averages; and
Disseminate performance reports more frequently than the current  annual distribution—for example, semiannually. As we noted, such benchmarks reflect more local  patterns of care that may be more relevant to physicians than  comparisons to national averages alone. We followed the same methodology for comparing how private entities  and the Centers for Medicare & Medicaid Services (CMS) conduct  performance feedback reporting for hospitals as we did for examining  physician-focused feedback programs. We interviewed representatives of  the nine selected private entities about their feedback reporting to  hospitals, if any, with regard to report recipients, data sources used, types  of performance measures and benchmarks, frequency of reporting, and  efforts to enhance the utility of performance reports. These entities used their discretion to determine which measures to  include in their reports. Medicare Physician Payment: Private-Sector Initiatives Can Help Inform  CMS Quality and Efficiency Incentive Efforts.
Why GAO Did This Study

Health care payers—including Medicare—are increasingly using VBP to reward the quality and efficiency instead of just the volume of care delivered. Both traditional and newer delivery models use this approach to incentivize providers to improve their performance. Feedback reports serve to inform providers of their results on various measures relative to established targets. The American Taxpayer Relief Act of 2012 mandated that GAO compare private entity and Medicare performance feedback reporting activities.
GAO examined (1) how and when private entities report performance data to physicians, and what information they report; and (2) how the timing and approach CMS uses to report performance data compare to that of private entities. GAO contacted nine entities—health insurers and statewide collaboratives—recognized for their performance reporting programs. Focusing on physician feedback, GAO obtained information regarding report recipients, data sources used, types of performance measures and benchmarks, frequency of reporting, and efforts to enhance the utility of performance reports. GAO obtained similar information from CMS about its Medicare feedback efforts.

What GAO Found

Private entities GAO reviewed for this study selected a range of measures and benchmarks to assess physician group performance, and provided feedback reports to physicians more than once a year. Private entities almost exclusively focused their feedback efforts on primary care physician groups participating in medical homes and accountable care organizations, which hold physicians responsible for the quality and cost of all services provided. They limited their feedback reporting to those with a sufficient number of enrollees to ensure the reliability of reported measures. The entities decided on the number and type of measures for their reports, and compared each group's performance to multiple benchmarks, including peer group averages or past performance. All the entities used quality measures, and some also used utilization or cost measures. Because of the variety of quality measures and benchmarks, feedback report content differed across the entities. Some entities noted that in addition to national benchmarks, they compared results to state or regional level rates to reflect local patterns of care which may be more relevant to their physicians. Most health insurers spent from 4 to 6 months to generate their performance reports, a period that allowed them to amass claims data as well as to make adjustments and perform checks on the measure calculations. Commonly, private entities issued interim feedback reports, covering a 1-year measurement period, on a rolling monthly, quarterly, or semiannual schedule. They told GAO that physicians valued frequent feedback in order to make changes that could result in better performance at the end of the measurement period.
Feedback from the Centers for Medicare & Medicaid Services (CMS) included quality measures determined by each medical group, along with comparison to only one benchmark, and CMS did not provide interim reports to physicians. The agency has phased in performance feedback in order to meet its mandate to apply value-based payment (VBP) to all physicians in Medicare by 2017, a challenge not faced by private entities. In September 2013, CMS made feedback reports available to 6,779 physician groups. While private entities in this study chose the measures for their reports, CMS tied the selection of specific quality measures to groups' chosen method of submitting performance data. Although both CMS and private entities focused their feedback on preventive care and management of specific diseases, CMS's reports contained more information on costs and outcomes than some entities. While private entities employed multiple benchmarks, the agency only compared each group's results to the national average rates of all physician groups that submitted data on any given measure. CMS's use of a single benchmark precludes physicians from viewing their performance in fuller context, such as relative to their peers in the same geographic areas. CMS's report generation process took 9 months to complete, several months longer than health insurers in the study, although it included more steps. In contrast to private entity reporting, CMS sent its feedback report to physicians once a year, a frequency that may limit physicians' opportunity to make improvements in advance of their annual payment adjustments.
The Department of Health and Human Services generally concurred with GAO's recommendations and asked for additional information pertaining to the potential value of using multiple benchmarks to assess Medicare physicians' performance.

What GAO Recommends

The Administrator of CMS should consider expanding performance benchmarks to include state or regional averages, and disseminating feedback reports more frequently than the current annual distribution.