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• Data Development
• Health Care Reform
• Health Information Technology
• Medicaid and CHIP
• Medicare
• Mental Health and Substance Abuse
• Payment Policies and Costs
• Public and Population Health
• Quality and Health System Functioning
• State Health Policy

Developing Resource Use Reports for Medicare Fee-for-Service Claims

One facet of health care reform focuses on appropriate incentives to encourage health care providers to deliver high quality care while avoiding unnecessary costs, which is also the underlying principle of value-based purchasing (VBP). Development of a broad array of consensus-based clinical measures, effective resource utilization measures, patient safety and patient experience measures, and payment system redesign are cornerstones of this type of purchasing.

In an effort to move from a passive payer to an active purchaser of high-value health care, the Centers for Medicare and Medicaid Services (CMS) is currently developing and implementing a number of VBP initiatives in multiple settings of care. The agency-wide VBP initiatives include physician practices, hospitals, nursing homes, home health agencies, and dialysis facilities. Over the past 2-1/2 years, Mathematica has been assisting CMS with designing a system to implement physician VBP for Medicare beneficiaries, which includes development and distribution of confidential physician feedback reports that inform physicians of their performance on quality and cost. Physician feedback reports are one important aspect of VBP designed to spur health care improvements, along with public reporting of physician performance and encouragement of joint accountability among providers for providing care to a population of beneficiaries.

CMS has been developing and distributing physician feedback reports in phases, in anticipation of a national scale-up of reports for all physicians by 2015. In Phase I, Mathematica expanded the capability of CMS to process Medicare fee-for-service claims through commercial episode grouper products; developed per capita cost measures; explored alternative risk adjustment, attribution, reliability, and benchmarking options; and distributed feedback reports to approximately 230 physicians in 12 diverse sites across the U.S. to solicit their views on the reports. Participating organizations for Phase I included the Center for Studying Health System Change; Acumen, LLC; Ingenix; and Thomson Reuters.

In Phase II, Mathematica has been assisting CMS with expanding Phase I measures to include indicators of physician clinical quality, applying measures to broader accountable care entities, and crafting an approach for “scaling-up” the distribution of feedback reports. Phase II reports, tested with a large sample of physicians as in Phase I, will be distributed to approximately 2,000 physicians and 40 medical groups in 2010. Additionally, we have been helping CMS to design a physician VBP program, including potential design features for accountable care entities, beneficiary and provider assignment, performance measurement, and a physician payment system based on the value, rather than the volume of services provided. Phase II participating organizations include the Center for Studying Health System Change; America's Health Insurance Plans; Booz Allen Hamilton; Boston University; Brandeis University; CGI Federal; Ingenix; Iowa Foundation for Medical Care; MassPro; Palmetto, GBA; SAS Institute, Sewell, Inc.; Social & Scientific Systems, Inc.; and Thomson Reuters.

To view a Phase I feedback report prototype and sample per episode cost reports for acute myocardial infarction, cholecystitis, prostate cancer, lower or upper GU system infection, bacterial lung infections, and chronic obstructive pulmonary disease, click here.

Presentations

"What Physicians Think About Resource Use Reports." AcademyHealth Annual Research Meeting  (June 2009)