How to predict performance in value-based pay models


CMS’ Quality and Resource Use Report can help you understand your practice’s costs, says Robert A. Dowling, MD.

In September 2018, the Centers for Medicare & Medicaid Services (CMS) announced that the Quality and Resource Use Reports (QRURs) and Physician Quality Reporting System (PQRS) Feedback Reports will no longer be available after the end of 2018. These reports offer valuable insight into urologists’ performance compared to peers and benchmarks in two programs (Value-Based Payment Modifier, PQRS) that have been transitioned into the Merit-based Incentive Payment System (MIPS). If you have not already done so, you should download these reports from the CMS website 


before the end of 2018.

While the payment adjustments from these 2016 programs have already occurred in 2018, the QRUR in particular contains actionable information for your practice. Furthermore, my interpretation of recent reports from CMS indicate that the patient- and physician-level detail available in the 2016 QRUR may not be forthcoming under MIPS reporting (Cost Category). This article, then, will focus on how to use your 2016 report to understand your practice’s “costs” and how to begin to influence those costs.


How are patients attributed to your practice?

The Cost Category for MIPS includes the same two measures found in your 2016 QRUR: Total Per Capita Costs for All Attributed Beneficiaries (TPCC) and Medicare Spending Per Beneficiary (MSPB). It is important to understand how patients are attributed to your practice for these measures in order to analyze your report and act on it.

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For the first measure, TPCC, a patient is attributed to your practice (defined as providers billing under your tax ID number [TIN]) through a two-step process ( First, if the patient received primary care services (evaluation and management codes) from a primary care physician (PCP), nurse practitioner (NP), or physician assistant (PA), then the patient is attributed to that primary care TIN with the most allowed charges. If the patient cannot be attributed during step 1, then they are attributed to the non-PCP provider with the most primary care services.

Attribution for MSPB is completely different: Patients are attributed only if they had an inpatient hospitalization (episode), and attributed to the TIN who had the plurality of Medicare Part B (physician fee schedule) charges during the episode. With these definitions in mind, it is time to look in detail at your QRUR and what actions you can take.

First, go to Exhibit 7-AAB (Costs for All Attributed Beneficiaries Domain) in your main report. There, you will find a summary of the two measures defined above, the per capita or per episode cost, and the standard deviation (SD) from the mean (benchmark). A negative score is better, and a variance greater than 1 standard deviation in either direction is significant. The SD was used to determine payment adjustments under the legacy Value-Based Payment Modifier Program; in the MIPS Cost Category, performance will be based on decile grouping.

Action(s) you should take: If your costs for either measure are greater than (positive) 1 SD from the mean, you should examine your supplemental tables in detail to determine why and form a plan to lower those costs to the extent you can (more on this later).

Next, open Table 2A (Beneficiaries Attributed to Your TIN for the Cost Measures). Here, you will find a list of all beneficiaries attributed to your TIN, the reason for attribution, the number of services incurred by providers in your TIN and outside your TIN, and whether the patient was hospitalized.

Action(s) you should take: Look at the Basis for Attribution column. If you have any step 1 patients, then it may be because your NP or PA is billing under their specialty type rather than your physicians’ (incident to). If all your patients are step 2, then you can assume that these patients did not see a PCP in 2016. Encouraging patients to maintain a relationship with a PCP is a good strategy for patient care coordination as well as ensuring that costs are allocated to your TIN only when your providers really are the most responsible for these patients’ care and costs. Examine the frequency of services/provider to see if you have outliers inside your TIN that you can address, or patterns outside your TIN.

Table 2B includes a summary of hospitalizations by facility for beneficiaries attributed under TPCC.

Action(s) you should take: This table reflects your potential partners for controlling costs, but otherwise is not actionable.

Continue to the next page for more.Table 2C includes beneficiary detail on all of the hospitalizations included in TPCC, including principal diagnosis, whether they were admitted through the ED, and unplanned readmissions. This table does not contain cost detail.

Action(s) you should take: Summarize this table by diagnosis to understand which hospitalizations were under your control-if most are genitourinary diagnoses, then you have an opportunity to raise awareness about the emergency room as a gateway to attributed costs and the importance of good communication between the ED and your providers before a decision to admit a patient.

Table 3B shows detailed cost information by category of service and inside and outside your TIN for TPCC.

Action(s) you can take: Using a spreadsheet or basic business intelligence tool, link this table to Table 2A and Table 2C using the patient identifier as the link/key. From these joined data, analyze costs by category and group into those you can control (in your TIN, categories you control such as major procedures) and those you cannot. Look for expensive outliers in your practice.

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Tables 4A-4D address attributed beneficiaries with chronic conditions, and there is no direct correlate for urologists in the Cost Category of MIPS. The information does serve as another reminder that patients with any non-urologic chronic condition should see a PCP and not be attributed to your TIN under the TPCC in Cost Category of MIPS.

Finally, Tables 5B (Beneficiaries and Episodes Attributed to Your TIN for the MSPB Measure) and 5D (MSPB Costs, by Episode and Service Category) are probably the most important tables to review. Linking these tables on the beneficiary will reveal detail on costs by provider, facility, diagnosis, and category. These are the costs that your TIN can influence.

Action(s) you can take: Using a spreadsheet, identify low- and high-cost providers, hospitals, and diagnoses. Use these apples-to-apples comparisons to steer patients to low-cost facilities where appropriate. Examine the charts of patients who were readmitted to the hospital within 30 days to see if they were preventable admissions.


Bottom line: This set of reports presents an opportunity to understand which physicians, facilities, and diagnoses have been associated with higher cost. Potential actions include raising awareness about costs of care, shifting referral patterns to lower cost facilities/physicians, implementing a workflow to ensure that patients with chronic conditions see a PCP at least once a year, and addressing how your practice controls urology-related ED visits that might result in hospitalization. While the information is somewhat dated (2016), this author believes the QRUR is predictive of a practice’s success under MIPS and future value-based reimbursement generally.

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