Lessons for Neurologists from Medicare Quality and Resource Use Reports

June 14, 2012

By Michael Kitchell, M.D. McFarland Clinic Ames, Iowa (mkitchell@mcfarlandclinic.com)

The ACA law has stipulated that Medicare will begin to pay physicians for higher quality and lower cost (spending per patient) starting in 2015. The basis for this is a compilation and rating of measures of quality and costs, called Medicare Quality and Resource Use Reports (QRUR). These QRUR were sent to over 23,000 physicians in Iowa, Kansas, Missouri and Nebraska in March 2012. In this report there were 487 neurologists in those states who were compared for their quality measures and costs per patient.

There are some lessons for our nation’s neurologists from the Medicare QRUR that were sent to individual physicians. I have had the opportunity, as board chair of a large multispecialty group, to see other primary care and specialists’ performance on these cost and quality measures.

Claims Data

QRUR measures of quality are mostly derived from administrative claims (billing) data from Medicare part A and B. Few neurologists have participated or succeeded in reporting quality measures through the Physician Quality Reporting System, so the PQRS with an average of 3 quality measures had little impact. There are 41 quality measures from claims data used in the QRUR, and they pertain to the patients that a neurologist saw in 2010. Those patients also saw many other physicians during the year. In fact, many neurologists had 10–15 other physicians who also saw their average patient. My average patient had 13 different physicians who treated them in 2010.

In my multi–specialty group we ranged from primary care physicians who had 10–12 other physicians who also saw their average patient, to our hospitalists who had 19–20 other physicians involved with the care of their average patient. My immediate question for CMS was, “who gets the credit (or blame) for the collective actions of those 10, or 20, other physicians?” The attribution of who did the action is not clear, and I have likened this QRUR report as not a “ballpark” guess, but a “neighborhood” measurement. The physicians who were involved with the care of a panel of patients collectively should get credit or blame, not an individual with questionable attribution.

My QRU report was for 605 Medicare patients that I saw in 2010, compared to the average neurologist in these four states who saw on average 339 Medicare patients. It is from these panels of patients that the quality and cost data for neurologists is derived, not the sole action of the neurologist.

Quality Measures

For the quality measures, almost all neurologists saw few QRUR quality measures that pertained to their neurologic services. The QRUR quality measures are mostly primary care measures, e.g. diabetic, pulmonary, cancer screening, and lipid testing, as well as monitoring of therapy and medication for different classes of drugs, for diseases such as heart disease and COPD.  There are also measures of drugs that should be avoided and negative drug–disease interactions such as antipsychotic drugs in patients with a history of falls and tricyclic antidepressants in demented patients.

Most of these 41 quality measures do not pertain to specialists, and of those reported quality measures, in my clinic’s experience less than half of the measures were frequent enough (30 patients who had a claim for the service) in the physician’s panel of their patients to be significant. Of the 17 quality measures that I had with 30 patients or more, my results were better than average for 14 of the 17.  I give credit to my medical neighborhood, especially our primary care physicians for these results.

There was no quality data comparing neurologists to other neurologists in these four states. The only quality comparisons were for the individual vs. the total of over 23,000 physicians of all specialties. But for cost comparisons there was data for the 487 neurologists’ panels of patients.

Cost Data

Cost comparisons were grouped into three categories. Physicians who directed the care of patients were those who had 35% or more of the outpatient E&M codes. Physicians who influenced the care of the patients were those who the physician had fewer than 35% of E&M visits but over 20% of the professional fees. Physicians who contributed to the care were those who had fewer than 35% of outpatient E&M visits and less than 20% of their professional costs.   

The neurologists who “directed” care had 46 as the average number of patients in this category. The average costs of these patients broke down as follows. The total cost of care for these patients averaged $9,842, and 2.8% of that spending went to neurologists for their care (E&M and procedure codes). The majority of Medicare spending went to hospitals, outpatient visits, ancillaries, post acute care, and “other services” at 88% of total spending. Other physician fees made up the other 9% of the total costs. The lesson here is even with neurologists “directing” care the total costs are mostly due to costs of care beyond the physician’s own fees.

In the category of neurologists who “influenced” care, the total spending on these patients was $7,861. Only 4.1% of the total cost was due to neurologists’ professional fees. In the “contributed” category only 0.6% of the total costs of $21,463 were spent on neurologists’ professional fees for an average of 268 patients per neurologist. The lessons from this category are that neurologists take care of very sick (expensive) patients, and neurologists’ share of the Medicare reimbursement pie in these states is only about 0.6%.  The percent of professional fees for all physicians involved with care out of the total costs was around 12–14%. The total costs of care for the year were even higher for patients with diabetes ($26,606), coronary artery disease ($26,759), COPD ($32,701), and heart failure ($36,115).

The Medical Neighborhood

Every neurologist had a scale for costs by percentile, so each neurologist would know where they were compared to the average total Medicare spending per patient per year. The lesson overall was that neurologists have only a partial role in both quality and cost. The “medical neighborhood” as I call it determines the physician’s quality and cost performance of those panels of patients.

Medicare will start to pay for higher quality and lower cost/patient in 2015 with the Value–based Payment Modifier (VBPM), and this type of report will be improved in some ways according to feedback CMS receives. Since this VBPM is budget neutral, some physicians in not–so–good neighborhoods will have pay cuts. The payment modifier will begin for some practices, most likely groups, in 2015 using cost and quality data from 2013. Medicare does adjust payments for sickness level differences (risk adjustment) as well as for geographic differences in local resource prices (price adjustment).

The overall lesson is there is little time to waste for neurologists to become involved with their medical neighborhood in which they practice, to improve both quality and cost performance. Quality measurement will evolve, and electronic health records will assist with data measurement, analysis, and feedback for all physicians to improve their processes of care, resulting in better outcomes for all patients.

Neurology will continue to play an important role in diagnosing and treating very ill (and expensive) patients. The value of neurologic care will become more obvious as quality and cost measures evolve.

Neurologists and the AAN need to lead–– or else follow what other entities decide—in improving patient outcomes while reducing the unsustainable increase in healthcare costs.

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