	Background

Physicians can be profiled on the health care they provide to Medicare  beneficiaries using measures in two performance dimensions: the  resources used to provide care to beneficiaries and the quality of that  care. CMS has established goals and made progress in developing its  Physician Feedback Program. The per episode method measures the resource use associated with  treating a specific episode of an illness in a beneficiary—for example, a  stroke or a hip fracture. CMS has implemented the program in phases by distributing feedback  reports to an increasing number of physicians in selected metropolitan  areas. CMS Tested Various Approaches but Still Faces Several Methodological Challenges in Developing Physician Feedback Reports

CMS faces challenges in selecting resource use and quality performance  measures that make feedback reports meaningful, reliable, and  actionable. While CMS has tested different approaches to developing feedback  reports, challenges remain in making methodological decisions that will  enable CMS to accomplish its program goals. Other Key Methodological Decisions Involve Trade- offs, and CMS Has Tested Different Approaches to Inform These Decisions

Determining risk adjustment factors. CMS faces trade-offs in deciding  which factors to use for risk adjustment, which accounts for differences  outside the physician’s control, such as beneficiary health status. A higher minimum  increases the reliability of the information, but decreases the number of  physicians eligible to receive a report. In Phase I, CMS conducted a statistical reliability test to determine the  minimum number of episodes a physician needed to be eligible for a  feedback report. Selecting peer groups for comparisons. CMS’s Plans for Improvement May Not Fully Address Challenges in Distributing Reports to Physicians

The majority of sampled physicians were not eligible to receive a Phase II  report after CMS’s methodological decisions were applied. Further, CMS faced multiple challenges with  the electronic distribution of feedback reports to eligible physicians, and  as a result, few physicians accessed their reports. CMS officials plan to  use a new distribution method for Phase III reports. Few Sampled Physicians Were Eligible to Receive a Feedback Report; Significantly Increasing Eligibility Will Continue to Be Challenging

Over 80 percent of CMS’s initial sample of 9,189 physicians were  ineligible to receive a Phase II feedback report after CMS’s  methodological decisions, such as minimum case size requirements,  were applied. Major challenges with Phase II distribution were CMS’s difficulty obtaining  physicians’ contact information, methods of electronic distribution that  were burdensome for physicians, and lack of a strong incentive for  physicians to review the reports. Moreover, CMS conducted  limited follow-up with profiled physicians to obtain their input on the  feedback reports. Recommendations for Executive Action

In order to develop feedback reports that are more reliable, credible,  accessible, and applicable to a greater number of Medicare physicians,  we recommend that the Administrator of CMS take the following four  actions:    Use methodological approaches that increase the number of  physicians eligible to receive a report, such as    multiple provider attribution methods, which could also enhance  credibility of the reports with physicians, and    distributing feedback reports that include only resource use  information, if quality information is unavailable. Identify factors that may have prevented physicians from accessing  their reports and, as applicable, develop strategies to improve the  process for distributing reports and facilitating physicians’ access to  them. These actions include refining the attribution methodology to increase the  number of physicians receiving feedback reports in Phase III, analyzing  the number of cases required to reliably measure quality and make  credible comparisons, developing new strategies for distributing feedback  reports, and obtaining input from individual physicians and physician  groups about the information contained in the feedback reports.
Why GAO Did This Study

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) directed the Department of Health and Human Services (HHS) to develop a program to give physicians confidential feedback on the resources used to provide care to Medicare beneficiaries. In response, HHS's Centers for Medicare & Medicaid Services (CMS) has established and implemented the Physician Feedback Program by distributing feedback reports to an increasing number of physicians that provided data on resources used and the quality of care. MIPPA mandated that GAO conduct a study of this program. To address this mandate, GAO identified (1) methodological challenges CMS faces in developing feedback reports and approaches CMS has tested to address them and (2) challenges CMS faces in distributing feedback reports and CMS's plans to address them. GAO interviewed CMS officials and representatives from the program contractor and reviewed relevant documentation.

What GAO Found

CMS faces challenges incorporating resource use and quality measures for physician feedback reports that are meaningful, actionable, and reliable. CMS had difficulty measuring the resources used by physicians to treat specific episodes of an illness, such as a stroke or a hip fracture, and the quality measures it used in the program's most recent phase applied to a limited number of physicians. CMS must also make decisions to address several other methodological challenges with developing feedback reports: how to account for differences in beneficiary health status, how to attribute beneficiaries to physicians, how to determine the minimum number of beneficiaries a physician needs to treat to receive a report, and how to select physicians' peer groups for comparison. These decisions involve trade-offs; for example, a higher minimum case size requirement increases the reliability of the information in the reports, but it decreases the number of physicians eligible to receive one. While CMS has tested different approaches to measuring and comparing physician performance, methodological difficulties remain in developing feedback reports. CMS also faced challenges distributing feedback reports to physicians that its plans for improvement may not entirely address. In the most recent phase of the program, about 82 percent of physicians in CMS's sample were not eligible to receive a report after CMS's methodological decisions were applied. CMS plans to make a number of methodological changes in the next phase, but significantly increasing eligibility will continue to be challenging. The electronic distribution of feedback reports also presented multiple challenges that resulted in few physicians accessing their electronic reports in the most recent phase. Factors that may have contributed to this low access rate include CMS's difficulty in obtaining accurate contact information, burdensome methods for electronic distribution, and lack of a strong incentive for physicians to review their reports. CMS conducted limited follow-up with physicians for whom feedback reports were produced. CMS plans to use a new distribution method in a four-state region in the next reporting phase.

What GAO Recommends

GAO is recommending that CMS use methodological approaches that increase physician eligibility for reports, statistically analyze the impact of its methodological decisions on report reliability, identify and address factors that may have prevented physicians from reading reports, and obtain input from a sample of physicians on the usefulness and credibility of reports. CMS concurred with these recommendations.