2011 GPRO I QRUR MethodologyDETAILED METHODOLOGY FOR THE 2011 MEDICAL GROUP PRACTICEQUALITY AND RESOURCE USE REPORTSI.OverviewA. What are the 2011 Quality and Resource Use Reports?The 2011 Quality Use and Resource Reports (QRURs) for medical group practices areconfidential feedback reports provided to practices that participated in the Group PracticeReporting Option (GPRO I) of the Physician Quality Reporting System (PQRS) in 2011. Thesereports contain information previously provided by the Centers for Medicare & MedicaidServices (CMS) separately in two reports—the QRUR and the PQRS GPRO I FeedbackReport—on the quality of care provided to Medicare fee-for-service (FFS) beneficiaries whomthese groups treated in 2011, as well as the resources used to provide that care and the incentivepayment earned under the GPRO I program.To participate in the GPRO I program in 2011, a medical group practice needed to submit aself-nomination letter to CMS and be selected to participate. Eligible group practices weredefined by a single taxpayer identification number and must have included at least 200 eligibleprofessionals, as identified by their individual National Provider Identifiers, who had reassignedtheir billing rights to the taxpayer identification number. 1The feedback reports are integral to CMS’ efforts to support value-based purchasinginitiatives to enhance the quality and efficiency of health care services provided to Medicarebeneficiaries (see box on following page for more information). CMS has pursued a phasedapproach to physician feedback reporting as a way to expand understanding of policy issuesrelated to measuring physician-driven costs of care and quality. In the current phase of theprogram, CMS continues to test the design, content, and performance indicators included inphysician feedback reports.The Physician Feedback Program also addresses Section 3007 of the 2010 Affordable CareAct, which directs the Secretary of Health and Human Services to develop and implement abudget-neutral payment system that will employ a value-based payment modifier (VBM). TheVBM will be used to adjust Medicare physician fee schedule payments based on the quality andcost of care physicians deliver to Medicare beneficiaries. The VBM will be phased in over atwo-year period, beginning in 2015. In 2015, the VBM will be based on performance and costsfrom calendar year 2013. The current QRURs include some performance measures that may beused for the VBM.1In addition, the practice was required to satisfy a number of technical criteria. For more information, s-Patient-AssessmentInstruments/PQRS/Group Practice Reporting Option.html.November 20121Centers for Medicare & Medicaid Statistics

2011 GPRO I QRUR MethodologyThe Physician Feedback Program and the Value-Based Payment ModifierTo enhance the quality and efficiency of health care services provided to Medicarebeneficiaries, CMS is developing and implementing a set of value-based purchasing initiativesacross many health care settings, including physician practices. To support these initiatives,CMS has been developing physician resource use and quality measures, evaluating physicians ontheir comparative quality and resource use, and educating physicians about the efficient use ofresources. These efforts support expanded physician feedback reports detailing physician qualityand cost performance, and performance-based payment.As part of its value-based purchasing initiatives, for the past several years CMS hasdisseminated under the Physician Feedback Program a limited number of confidential reports tophysicians and medical group practices that include measures of resource use and quality. CMShas pursued a phased approach to physician feedback reporting as a way to expandunderstanding of policy issues related to measuring physician-driven costs of care and quality.In the first phase of the approach (in 2009), CMS distributed and tested approximately 300reports that included individual physician-level cost measures. The Physician Feedback Programwas expanded under Section 3003 of the 2010 Affordable Care Act, which required the Secretaryof Health and Human Services to provide confidential information to physicians and groups ofphysicians about the quality of care furnished to Medicare beneficiaries compared to the cost ofthat care. In the second phase of the approach (in fall 2010), CMS distributed a larger number ofreports, to both individual physicians (about 1,700) and medical group practices (36), andexpanded these reports to include selected quality measures. In the most recent phase of theprogram, CMS distributed QRURs in fall 2011 to all medical group practices participating inGPRO I in 2010, followed by the dissemination in early 2012 of approximately 24,000 QRURsto physicians who practiced in Iowa, Kansas, Missouri, or Nebraska in 2010. In the currentphase of the program (2012–2013), CMS continues to test the design, content, and performanceindicators included in physician feedback reports.The Physician Feedback Program also supports Section 3007 of the 2010 Affordable CareAct, which directs the Secretary to develop and implement a budget-neutral payment system thatwill employ a value-based payment modifier. The payment modifier will be used to adjustMedicare physician fee schedule payments based on the quality and cost of care physiciansdeliver to Medicare beneficiaries. The Secretary will phase in the payment modifier over a twoyear period, beginning in 2015, with the initial performance period proposed to be 2013. In2015, the value-based payment modifier will be calculated on the bases of cost and quality dataderived from services delivered in calendar year 2013. In 2015, CMS has proposed that thevalue-based payment modifier be applied at the tax identification number level for physicianswho during calendar year 2013 practiced in medical groups of 100 or more eligibleprofessionals. Beginning in 2017, all physicians paid under the Medicare physician fee schedulewill be affected by the modifier.In order to give physicians a preview of performance measures that might be used indetermining the payment modifier, the 2011 physician feedback reports are being disseminatedto much larger numbers of physicians and medical group practices than in earlier phases.November 20122Centers for Medicare & Medicaid Statistics

2011 GPRO I QRUR MethodologyB. What are the Goals of the QRURs?A primary goal of these reports is to support the efforts of physicians and medical grouppractices to provide high quality care to their Medicare FFS patients in an efficient and effectivemanner. A second goal is to provide physicians and medical group practices with quality-of-careand resource use information that could be used in the future VBM.C. What Information is Included in the QRURs?The QRURs contain information on both quality of care and resource use, as well as anyincentive earned by the GPRO I participant under the PQRS program. A group’s quality isassessed primarily based on what portion of the group’s Medicare patients (represented by asample) received 26 recommended core clinical interventions. These 26 National QualityForum–endorsed quality measures target high-cost chronic conditions—diabetes mellitus, heartfailure, coronary artery disease (CAD), and hypertension—and preventive care. The GPRO toolused to collect clinical information for the measures is virtually identical to the data collectiontool employed in CMS’ Physician Group Practice demonstration. In addition to these 26 qualityindicators, the QRURs include information on admissions for ambulatory care–sensitiveconditions (ACSCs), 30-day hospital readmission rates, and the rate at which patients see aphysician within 30 days of a hospital discharge.To assess resource use, beneficiary costs, as identified in Medicare claims, are paymentstandardized (to remove geographic Medicare payment differences) and risk adjusted. Per capita(per patient) costs are then computed for each group’s attributed patients. Per capita costs arealso reported for patients with specific chronic conditions, such as diabetes. Each group’sperformance on both quality and resource use measures is compared to the performance of allother GPRO I groups. Group performance on quality measures also is compared to a “nationalbenchmark” comprising all groups and individuals reporting on the measure.This document offers a detailed explanation of the methodology employed to produce thestatistics presented in the reports. Exhibit 1 displays a brief description of the major steps inreport development on the pathway from beneficiary attribution to performance assessmentbased on peer comparisons for the 2011 QRURs. Appendix A includes a detailed description ofthe data used to compute the statistics included in the report.D. How Do the 2011 QRURs Differ from the 2010 QRURs?In response to stakeholder feedback and as part of a continuing effort to enhance theusefulness and expand the reach of the QRURs, CMS has made the following changes to theQRURs for medical group practices participating in the group practice reporting option (GPROI) of the Physician Quality Reporting System (PQRS) in program year (PY) 2011:1. Update payment standardization algorithm. Beginning with PY2011, a CMSagency-wide approach to payment standardization is replacing the QRUR-specificalgorithms used previously. This change is intended to result in a more uniform andtransparent approach to payment standardization across agency initiatives. Moreinformation about the payment standardization algorithm is available at Page&pagename QnetPublic%2FPage%2FQnetTier4&cid 1228772057350.November 20123Centers for Medicare & Medicaid Statistics

2011 GPRO I QRUR Methodology2. Incorporate incentive information. The PY2011 QRURs include information onany incentive earned by the report recipient based on participation in GPRO I.Information provided on the Highlights page , indicates whether an incentive wasearned and the size of the incentive, disaggregated by Medicare AdministrativeContractor.3. Include more refined benchmarks. To better enable report recipients to assesstheir performance relative to other medical group practices participating in GPRO I,information on performance relative to the 25th, 50th, 75th, and 95th percentiles isincluded both on the Highlights page and in the body of the PY2011 QRURs. Inaddition, performance on quality measures is now compared not only to theperformance of other GPRO I medical group practices but also to performanceamong all PQRS participants reporting the measure.4. Provide additional information on the relationship with attributed beneficiaries.The PY2011 QRURs include information on the average number of evaluation andmanagement (E&M) visits to all providers by beneficiaries attributed to the reportrecipient and the recipient’s share of those visits. In addition, the reports describewhich types of medical professional—primary care physicians, medical specialists,surgeons, emergency medicine physicians, other physicians, and other eligibleprofessionals—were responsible for providing most of the medical group practice’sE&M services to attributed beneficiaries in 2011.5. Modify reported ambulatory care sensitive conditions (ACSCs). In contrast withprevious QRURs, the acute condition ACSCs—namely, bacterial pneumonia, urinarytract infection, and dehydration—are now combined into a single acute conditionscomposite ACSC.6. Add measures on hospital readmission and care after hospital discharge. ThePY2011 QRURs include two new outcomes measures, which have been previouslyreported under the Physician Group Practice Transition Demonstration: (1) the allcause 30-day hospital readmission rate per 1,000 discharges of attributedbeneficiaries and (2) the number of attributed beneficiaries discharged from thehospital who saw a physician within 30 days per 1,000 discharges.7. Expand reporting of hospitals admitting attributed beneficiaries. To providegreater information on which hospitals admitted a medical group practice’s patientsduring the performance period, the PY2011 QRURs report the name and number ofstays for all hospitals that accounted for at least 5 percent—rather than 10 percent, aspreviously—of all admissions among the group’s attributed beneficiaries.8. Provide detailed information on emergency services. In reporting detailedinformation on the cost of specific services used by attributed beneficiaries, thePY2011 QRURs separate out emergency services that do not result in an inpatientadmission from other outpatient services, whereas previously these services werereported together as outpatient services.9. Identify hospital admissions from the emergency department. In addition tocontinuing to report the number of hospital admissions per 1,000 attributedbeneficiaries with conditions such as diabetes and coronary artery disease, thePY2011 QRURs also report what percentage of these admissions was from theemergency department.November 20124Centers for Medicare & Medicaid Statistics

2011 GPRO I QRUR MethodologyExhibit 1. Pathway from Beneficiary Attribution to Performance Assessment, 2011 GPRO I QRURsII. How are Medicare Beneficiaries Attributed to Group Practices?A. AttributionUnder the PQRS GPRO I program, Medicare beneficiaries were attributed to the singlemedical group practice that submitted claims to its carrier or Medicare Administrative Contractor(MAC) for at least two office or other outpatient evaluation and management (E&M) servicesbetween January 1, 2011, and approximately October 31, 2011, and billed for a larger share ofthe beneficiary’s E&M services (as measured by Medicare allowed charges) than any otherNovember 20125Centers for Medicare & Medicaid Statistics

2011 GPRO I QRUR Methodologyphysician practice during that time. 2 The Current Procedural Terminology E&M codes used toattribute