SCGhealth Blog

Choosing Wisely: because sometimes less is more

Tuesday, July 26, 2016

by Angela Little

How it became cool to choose wisely
Created in 2012 by the American Board of Internal Medicine Foundation, the Choosing Wisely® initiative encourages physicians to use evidence-based recommendations when making care decisions for their patients. The initiative’s goal is to identify and promote healthcare that is:
• Supported by evidence
• Not duplicative of other tests or procedures the patient has already received
• Free from harm
• Truly necessary

Choosing Wisely began with recommendations from just nine medical organizations. It’s expanded to include more than 70 specialty societies. Each one produces an evidence-based list of tests and procedures they consider to be overused and potentially harmful. Many – though not all – of the services are related to diagnostic imaging.

Making care decisions based on evidence sounds great! So what’s the issue?

The cost of being wise
Physicians are increasingly being asked to embrace financial stewardship and payment reform. This also pushes them to consider the value of the services they provide. Low-value services are defined as common tests and procedures that are frequently overused or misused. But there continues to be little agreement on which services to classify as low-value. And there’s no consensus on which mechanisms are most cost-effective in reducing the use of these low-value services.

Although widely discussed, the healthcare system has been slow to effectively discourage service overuse. According to a recent study from The Dartmouth Institute for Health Policy and Clinical Practice, most physicians agree that while they have a responsibility to control costs, more than one-third don't know how much tests and procedures actually cost. And about one in three say they don’t consider cost when making medical decisions.

Wisely addressing the elephant in the room
Change can be hard, even when physicians agree to the need behind it. There are a number of barriers to changing how physician’s practice. One is the undeniable presence of the elephant in the room — the incentives, particularly financial ones, for ordering low-value tests and treatments. After all, in a fee-for-service system, most delivery systems continue to be paid for tests and drugs, regardless of their appropriateness or indication. Payers are then able to pass on these costs to employers and patients, creating a vicious cycle.

Despite the elephant in the room, it’s natural to wonder: Is Choosing Wisely working? Analysis points to the fact that while there’s a willingness on the part of physicians to forgo low-value care services, there needs to be further engagement with more than just physicians. To really begin to see the impact of Choosing Wisely, and to see a meaningful reduction in the use of low-value services, there must be appropriate support to address patient demand, malpractice concerns, and other drivers of overuse. The behaviors and attitudes of patients, regulators, pharmaceutical companies, and other stakeholders also play a crucial part in the consumption of low-value services.

The challenge of being wise
Efforts to reduce low-value care can decrease spending while helping patients avoid potentially harmful treatments. However, these efforts face enormous challenges.

One major challenge is patient understanding of health information. According to the U.S. Department of Health and Human Services, nearly nine out of 10 adults have difficulty using the everyday health information that’s routinely made available to them. Without clear information and an understanding of how to prevent and self-manage conditions, these individuals are more likely to skip necessary medical tests and insist on those that are unnecessary. They also end up in the emergency room more often, and have a hard time managing chronic diseases.

Another challenge is agreeing on a strategy to reduce low-value care. Currently, there are two approaches for reducing low-value care.First, professional societies are exhorting physicians to consider both cost and value when deciding among alternative treatments. This strategy appeals to a physician’s sense of professionalism by promoting the idea that they are stewards of societal resources. Second, payers are promoting healthcare system innovation and implementing payment reforms to reduce incentives for providing ineffective treatments. Unfortunately, discussions about how to reduce low-value care often gloss over a crucial third strategy: a sustained effort to generate evidence that will distinguish between high and low-value care.

When it comes to reducing unnecessary tests and treatments, clinical decision-making is just one piece of the puzzle. More targeted research, including comparative effectiveness, would help determine which treatments or services are low-value. While it’s not feasible to conduct a trial on every service mentioned in the Choosing Wisely recommendations, the lack of high-quality evidence will hamper efforts to reduce low-value care. Clinicians are more likely to respond to a recommendation to avoid a low-value treatment if it’s based on sound evidence, than if it’s justified on the grounds that the treatment has never proven to be superior to another one. The absence of evidence is not the same as evidence of ineffectiveness. And healthcare system leaders and administrators may have difficulty convincing front-line physicians to change practice patterns without appropriate evidence.

It takes a village to be wise
Based on a recent survey, only one in five doctors is aware of the Choosing Wisely initiative. Even more disappointing, of those doctors who do know about the campaign, 53 percent say that when a patient asks for an unnecessary test or procedure, they order it anyway.

In a healthcare system that continues to reward volume, the switch to evidence-based medicine remains an up-hill battle. To effect real change, patients must be advocates for their own health and learn that “Choosing Wisely” means making thoughtful, well-reasoned healthcare decisions. By normalizing conversations that have been notoriously off limits, Choosing Wisely will continue to drive care that focuses on the physical, mental, emotional and financial health of the patient.

Learn more about Choosing Wisely.

PQRS Contingency Planning

Thursday, January 14, 2016

By: Jennifer Searfoss, CEO

**EXTENDED REPORTING DEADLINE** The Medicare quality reporting program runs on a calendar year basis. So it might be a relief to know that you still have time to figure out if you have enough data into Medicare to meet and exceed last year's requirements. The Physician Quality Reporting System (PQRS) has several options to get data to the Centers for Medicare & Medicaid Services (CMS). And some of these options are still open, but you need to get moving!

Photo credit: GraphicStock © 2016.

For groups that chose the free option of sending in data to CMS through claims-based reporting, you only could submit data on the first claim you sent in for that date of service. The federal health plan stated that you can't correct missed data by calling in a corrected claim. Its a once and done data submission option.

That means you may not have enough data submitted already. Or you may not have enough to meet the performance targets under the value-based modifier (VBM). There is still time to fix this!

PQRS requirements

  • Report on 50% of eligible encounters with traditional Medicare patients
  • Report on 9 measures*
  • Have performed the measure atleast once

VBM Requirements

  • PQRS performance rate must be in-line
    with the national average

* If you don't have data for nine measures, consider using the registry reporting option for measure groups. This allows you to report on a series of measures for 20 patients. Eleven of the patients must be traditional Medicare but the remaining nine could be commercial insurance, Medicaid or Medicare Advantage patients. Read more below.

Reporting options
For individual clinicians, including physicians and non-physician practitioners submitting claims to Medicare (including non-participating physicians), the alternative reporting options available after the end of the calendar year are through (1) a qualified registry or (2) electronic medical record (EMR) reporting.

Qualified registries are Medicare-acknowledged companies that aggregate data you send to them and forward it onto CMS in the Agency approved format. EMR reporting is either directly through your EMR vender OR can be handled separately through a data service vender where again the company formats the data and gets it to CMS.There is a fee, often for each clinician reporting, to use either of these methods.

Top option: Registries in our experience
So far, the majority of our Clients seeking solutions for gaps in data have chosen to go with registries. Why you might ask? Well, often there is a reason that we are coming up with solutions to fill data gaps. Sometimes its that physicians didn't hit the right button on the EMR for all nine measures to populate. Other times its that the measures that are most clinically appropriate for that physician are not clinical quality measures captured through the system. And then some times we have data that was submitted through the claims-based reporting method - but it wasn't for more than 50 percent of eligible encounters with Medicare patients so we need to go in and backfill with "performance not met" information. REMEMBER, the PQRS penalty in 2017 is for reporting not performance! So our focus is to get enough data to hit that 50% threshold which includes a mix of performance met and performance not met information.

Every PQRS Qualified Registry is different on when they require data to come into their system to meet the timeframe of getting it to CMS. The two companies SCG Health has worked with in the past have the following deadlines:

   PQRS Qualified Registry
Data Submission Deadline
   PQRS Pro (Healthmonix)
 March 18, 2016 at 11:59pm ET
   PQRS Wizard
 March 21, 2016 at 5:00pm ET  


Our advice from past submissions: DO NOT WAIT UNTIL THE DEADLINE to report data. We had one vender's system crash during the final hours of data submission. So, we strongly recommend that you sign up and pay for the service in early February and submit data at least one week prior to the deadline. For the list of 2015 PQRS Qualified Registries, check this out.

Assessing if you have enough data

What if you, for whatever reason, don't have data on nine measures? We strongly encourage you to check out the measure groups that also can be reported through the qualified registries. For measure groups, it is a defined set of measures that are reported on 20 or more patients. Eleven of the patients must be traditional Medicare. The remaining nine could be commercial insurance, Medicaid or Medicare Advantage patients.

There are a number of different measure groups, but the top ones we have Clients using are: Diabetes, Preventive Care, General Surgery and Total Knee Replacement. Here is the full list of 2015 measure groups.

Performance does matter; but not for PQRS

But lets say you have enough data but don't have strong performance numbers? Why does this matter if PQRS is on reporting and not performance? That's because of the Value Based Modifier (VBM), which is a separate penalty from PQRS and meaningful use, evaluates all clinicians attributed to the group tax identification number (TIN) for quality and cost. Primary care groups that do well in cost and quality can get a bonus payment for care coordination. For specialists, the goal is to be average and get a zero update. Groups considered low quality and high cost can receive up to a 4% penalty in 2017 based on 2015 performance. That's why performance matters.

Check out the 2013 performance targets. SCG Health has requested the 2014 performance targets from CMS.

If you don't know where to start with PQRS reporting, please give SCG Health a call.
This is what we specialize in!

SCG Health blog by Email

Recent Posts



SCG Health is a tradename of the Searfoss Consulting Group, LLC. You may reproduce materials available on this site for your own personal use and for noncommercial distribution. For more information, please read the Content Sharing Policy. Art & design by SCG Health. DISCLAIMER: You should consult an attorney for individual advice regarding a particular set of facts and circumstances. SCG Health reserves the right to change the information on this website without notice.