Data Changes the Doctors' Game

Dr. Data, you are being paged. Please respond.

For physicians, data sharing with the government is becoming essential and will impact how they get paid, receive bonuses or are penalized. While the data collection process is crucial, Niall Berman, director of the CMS Office of Information Products and Analysis, concedes it's fraught with uncertainty among providers.

Physicians have to realize, he said at a recent Washington D.C. conference, that "the game has changed."

At the daylong eHealth Iniative session on data and analytics this month, Berman cited one hot-button data sharing area the government is working on as it slowly moves from a fee-for-service world to a value-based one in healthcare. That sensitive area? It's determining physicians' pay.

Earlier this year, in a pilot program, CMS sent confidential reports to certain groups of physicians to allow them to "quantify and compare" their quality of care with peers, a data-sharing exercise that would ultimately impact their payments.

Physician Feedback reports were mailed to more than 23,000 Medicare fee-for-service physicians in large medical group practices in Iowa, Kansas, Missouri and Nebraska.

The reports detail physician per-capita cost and quality reporting information from 2010 that will be used under what is known as a "value-based modifier" for Medicare pay under the Affordable Care Act of 2010. The modifier is a key to providing different payments to physicians or groups of physicians under a fee schedule based on quality of care compared to costs.

Medicare is required to phase in the payments beginning in 2015 to physicians' groups of 25 or more. The value-based modifier payments would apply to all physicians in 2017.

CMS anticipates that payment incentives and penalties will be based under a proposed rule published July 30 in the Federal Register.  The Affordable Care Act has authorized CMS to penalize physicians who do not participate, up to 2% of allowable Medicare charges, with the same amount as incentive payments.

For those Midwest physicians who agreed to get an early taste of the move from fee-for-service to value, they haven't shown that they liked the data collection process very much—at least in early reports. The Medicare contractor for the area emailed the physician practices a web link to access the reports, but only 3,300 out of 23,730 downloaded them as of April, about 18%, giving a "cold shoulder" on filing the reports, according to the American Medical Association (AMA). Further updates haven't been released.

Last month, the AMA and more than 60 organizations pledged to help physicians better improve use of the data, which includes insurer information, to "enhance the quality and value of patient care."

Brennan concedes that some physicians are exasperated with the weekly and monthly flow of information. CMS wants the physicians to sort through the material, and evaluate their own practices. Unfortunately, some docs are overwhelmed. "We're physicians, not data analysts," Brennan recalled some physicians complaining.

Physician trepidation is not without merit, Brennan said, citing individual practioner concerns over privacy issues, for instance. "There is tension, of course," he said, noting that the government is working diligently "so we don't compromise individual privacy. We're trying to deal with that tension," he said.

Ultimately, failure by physicians to embrace data sharing will be counterproductive. Eventually, "every physician will be evaluated by quality resources based on (their information) that would result in bonuses or not," he said.

"We're harnessing raw data into actionable information at the point of care."  CMS hasn't much choice, Brennan said. The organization can't say a physician is "good or bad" without data.

CMS has been using the Physician Feedback reports over the past several years in evaluating proposals for value-based payment modifiers. The reporting "allows us to test different methodologies and to obtain stakeholder feedback that can be used to further refine the reports and inform our policy proposals and recommendations," CMS said in a statement about the proposed payment rules.

In addition, CMS said it "believes these quality initiatives aim to empower providers and consumers with information that would support the overall delivery and coordination of care and ultimately would support new payment systems." 

Despite the upbeat presentation by CMS, some physicians think otherwise. Peter W. Carmel, M.D., the former AMA president, said in a statement that the association continues to "have serious concerns that there are too many unresolved issues with these reports for CMS to use."

Lack of physician enthusiasm for CMS proposals is nothing new. After electronic reports were made available to 1,600 physicians and medical groups in 2010, fewer than 10% were downloaded, the AMA said, citing a Government Accountability Office report.

Barbara Sack, MHSA, executive director of the Midwest Orthopaedics medical staff in Shawnee Mission, KS, questioned the complexities of the reporting and wondered how CMS can evaluate quality to determine pay scales because of so many differences in an individual service line, with many subspecialties.

An orthopedics practice reflects many areas where there may seem to be quality differences, but because of variations of patient conditions, not how the work is performed, Sack told CMS in a recent conference call.

For instance, a sports-medicine physician may have lower costs because he sees "sports-minded people" as opposed to a foot and ankle surgeon who sees "patients who have uncontrolled diabetes" that may "cost more, but it's not due to his treatment," according to Sack. "It is due to the uncontrolled diabetes."

So the physician quality reports may differ dramatically without a true reflection of the quality of the doctor's work, she suggested.

"I'm trying to figure out how you're determining quality if you are basing it on these (reports)," she told CMS. Officials there acknowledge that they are still sorting out the role of subspecialties, but they believe a "tiered" structure would be implemented to take into account such quality differences among patient conditions.

Still, the data processing questions remain. CMS insists it is taking steps to engage physicians, but many docs aren't buying the CMS outreach, or are simply finding the process confusing.  Part of it is CMS's fault; another part, the physicians.

Obviously, "we're probably not where we want to be. We are just at the beginning of a sea change how we interact with providers," Brennan said. The government seeks "to harness the data to actual points of care," he said.

Sometimes, government feels caught in the middle, but certainly docs feel the same way about the data collection process. "You're damned if you do and damned if you don't," Brennan said.