Preparing for MACRA Implementation

FPs Embrace Quality and Resource Use Reports as Valuable Tools

November 02, 2016 12:53 pm Sheri Porter

As the nation moves toward implementing the Medicare Access and CHIP Reauthorization Act (MACRA) and value-based payment models, CMS is urging physicians to study their Quality and Resource Use Reports (QRURs).

Bob Rauner, M.D., seated, reviews a pie chart he created to show Jason Potts, M.D., center, and Brandon Webb, M.D., their clinics' combined 2015 Medicare costs as the physicians make final preparations to form an accountable care organization.

However, family physicians have reported much frustration when trying to access their reports from the CMS system. What's more, making sense of the information in the reports takes significant effort. So are QRURs worth the time and trouble? They sure are, say family physicians who've got some experience under their belts.

What a QRUR Reveals

FPs who've mastered QRURs told AAFP News the reports provide valuable insights into practice operations and give physicians a unique opportunity to assess the costs and quality of care they provide to Medicare patients.

"You can see how you've done on quality metrics and get a 'viewfinder look' at how far your enterprise has come," said Melissa Gerdes, M.D., of Dallas. The reports also provide a new way to look at resource utilization -- or "good stewardship of resources," she added.

Story Highlights
  • Although many family physicians are unfamiliar with Quality and Resource Use Reports, physicians who have learned how to use them say they are valuable and worth the time and effort.
  • The reports provide key insights into practice operations and give physicians a unique opportunity to assess the costs and quality of care they provide to Medicare patients.
  • The reports are a core component of the Merit-based Incentive Payment System (MIPS) going forward; the measurement period for MIPS begins Jan. 1, 2017, and will affect Medicare fee-for-service payment in 2019.

"Outside the classic ACO (accountable care organization) structure, practices aren't used to looking at utilization and trends and spends across the continuum," said Gerdes -- especially not numbers that are "benchmarked and compared to your region or nationally against your peers," as they are in these reports.

But there's another compelling reason why physicians need to get comfortable with QRURs.

"These reports are a core component of MIPS (the Merit-based Incentive Payment System) going forward," Gerdes noted. "The measurement period for MIPS begins Jan. 1, 2017, which will affect fee-for-service payment under Medicare in 2019.

"We've been talking about how these types of metrics are going to affect payments. That time is now here."

Gerdes is well-versed in systemwide medical care delivery. She left full-time clinical practice two years ago to become vice president and chief medical officer of the Methodist Patient-Centered Accountable Care Organization in Dallas, an organization that boasts a successful four-year track record in the Medicare Shared Savings Program.(19 page PDF)

Despite her organization's success, Gerdes knows many physicians are much less prepared. "This feels like a lot of chaos to them," she said. In fact, Gerdes noted that CMS estimates that possibly no more than 5 percent of physicians are even aware QRURs exist.

Best to start now, but be patient, she cautioned. Access your QRUR through the CMS Enterprise Portal.( An Enterprise Identity Management( account is required to obtain the 2015 reports. Call the QualityNet Help Desk at 866-288-8912 from 8 a.m. to 8 p.m. ET, Monday through Friday, or email the support desk for help.

Show and Tell Time

On a recent evening in Lincoln, Neb., Bob Rauner, M.D., M.P.H., sat down with physician colleagues from three clinics in the area to discuss their 2015 QRURs.

The clinics already are part of an independent physician association (IPA) -- OneHealth Nebraska -- and now Rauner is helping them finalize plans to form an ACO.

A pie chart created with the combined Quality and Resource Use Reports from three medical clinics in Lincoln, Neb., gives a perfect visual of their Medicare costs in percentages for 2015.

"The QRUR reports give physicians a snapshot of their clinics' performance last year," said Rauner. "This report provides useful information if physicians are starting an ACO or thinking about joining an ACO, because it tells them likely attribution numbers, where the money goes for their patient population and some places to start looking if they want to lower health care costs."

For example, for these three clinics, if the average cost of a Medicare patient is about $10,000, they know they'll have to save about $300 of that amount to qualify for shared savings the following year.

The QRUR gives users a "buckets of costs" -- for services such as CT scans, X-rays, hospice care and ER visits -- "and then compares those costs to your peers across the country," said Rauner.

"You can see if you have high-cost areas, low-cost areas -- where you are efficient and where you may need to improve."

As for the three clinics with which he recently met, after looking at their combined QRURs, the group discovered a couple of areas where their costs were above average. "If they can just limit those two areas, they could actually achieve a bonus in that next year," said Rauner.

Since leaving clinical practice in 2010, Rauner splits his time between public health work and guiding physicians through the rigors of clinical quality improvement work.

He urges small independent practices that are feeling overwhelmed to think about becoming part of an IPA or a rural ACO.

"I've found it's really helpful for people to share their information, and see who's doing better and why. Working in isolation is going to be harder and harder to do, and there's a lot of benefit to be gained by working with like-minded peers," he said.

Connecting the Dots

After a long history of caring for patients in clinical practice, Roger Fowler, M.D., of Tyler, Texas, got involved in the administrative side of medicine a few years ago. Today, he serves as medical director of population health at Christus Trinity Mother Frances Health Center.

His integrated health care organization is a Level 3 patient-centered medical home with some 360 providers.

Fowler said he believes in the triple aim of health care (better care, better outcomes, lower cost) and the efficient utilization of resources.

But he also knows this: "If we don't understand our costs of care, then we don't really get the whole picture."

Fowler said looking at the QRUR allows him to see, for instance, deviations in the cost of care for patient hospitalizations. If one area is high, he can dig down and find out why.

And because his organization participates in the Medicare Shared Savings Program, Fowler also gets monthly claims data from Medicare on attributed lives and has the benefit of having a third-party vendor to provide analysis of that data on an ongoing basis.

"So now I can see cost of care for our organization, and I can drill down to the individual physician level to learn how to connect the dots," said Fowler.

"If this is a high-quality physician (who) provides easy access for patients, and I see they have a lower cost of care, I can share that across my primary care offices -- 'You know, here's the secret to how we do this right. Patients don't like to go to the hospital; they like to see their primary care physician, but they go to the emergency department when they can't get an appointment.'"

Fowler said that's the kind of thought process that gives him the complete picture he needs to address patient needs, population health and costs.

But he also understands the frustration of his colleagues with fewer resources. "We're doctors. We should be spending our time taking care of people," said Fowler.

"The cost of care is the last thing we think of, because we believe that we are the ultimate patient advocate -- which I agree with -- but if we're going to be that advocate, we must also know if we are affordable."

And now, the QRUR is a way physicians can begin to see that for their Medicare patients.

Rob Freelove, M.D., and second-year resident Jenica Wessels Harwood, M.D., care for a patient in the Salina Family Healthcare Center in Salina, Kan. Freelove ensures his residents are prepared to work in a value-based health care system with regular reviews of the clinic's performance improvement and quality assessment reports.

"This is a rudimentary tool, the QRUR, but it gives us insights in this fee-for-service world about how we can be better if we're intentional about it. And it takes time and a team of people to help us. We can't do it alone," said Fowler.

Preparing Residents

Rob Freelove, M.D., of Salina, Kan., is CEO of Salina Family Healthcare Center and program director of the Smoky Hill Family Medicine Residency Program.

As a federally qualified health center (FQHC), his clinic is exempt from MACRA and the various programs associated with its implementation. So Freelove doesn't deal with QRURs, but he is still preparing residents for what they'll face when their training is complete.

"Most of our graduates are not going to work in an FQHC or in a clinic that's exempt, so they have to understand what MACRA is and how things work," he said.

Quality reporting, including the monitoring and tracking of certain health care outcomes, is built into the FQHC program, as are demographic and cost data. "It's all geared toward proving that we are providing care in an effective, efficient manner that utilizes the resources we're given," said Freelove.

Performance reports, quality assessments and quality improvement processes are regular and required parts of the training. "We print a report quarterly that includes our clinic's performance as a whole and also lists each person's individual performance so everybody can see how everybody else is doing," said Freelove.

"Physicians are competitive people, and nobody wants to see their name at the bottom of the list. So after those reports go out, there's a concerted effort by the people who are dragging behind to bring their numbers up."

Freelove frequently reminds residents that they will be measured and judged and that their reimbursement will be impacted by the results. "I tell them, 'If you don't learn that now, you will have a pretty steep learning curve when you get out.'"

Related AAFP News Coverage
QRUR 101: Understand, Utilize Quality and Resource Use Reports

More From AAFP
Family Practice Management: What You Need to Know About Medicare's New "Quality and Resource Use Report"
(November-December 2015)