AJMXXX10.1177/1062860615571662American Journal of Medical QualityPhillips et al


Maintenance of Certification, Medicare Quality Reporting, and Quality of Diabetes Care

American Journal of Medical Quality 1­–7 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860615571662 ajmq.sagepub.com

Robert L. Phillips, MD, MSPH1, Brenna Blackburn, MPH2, Lars E. Peterson, MD, PhD1, and James C. Puffer, MD1

Abstract Aligning maintenance of certification with quality reporting may ease reporting burden, but the impact on quality is uncertain. This study compared changes in quality measures from American Board of Family Medicine Performance in Practice Modules (PPMs), Physician Quality Reporting System (PQRS), and a combined PQRS/PPM for diabetes between 2008 and 2012. Physicians completed 7264 diabetes PPMs, 297 only reported PQRS measures 2 or more times, and 675 completed a combination project, representing more than 200 000 patients. After adjustment, PQRS and PQRS/PPM projects were associated with greater blood pressure and cholesterol control improvement than PPM only (P < .05). PPM-only projects had greater improvement than PQRS-only projects on 4 of 6 process measures and greater hemoglobin A1c improvement (P < .05) but were only better on 2 process measures and on hemoglobin A1c control than PQRS/PPM projects. These findings identify differences between quality reporting and quality improvement, suggesting reason to align the 2 programs. Keywords quality of care, quality reporting, quality improvement The American Board of Medical Specialties introduced Maintenance of Certification (MOC) in 2000, requiring implementation by all its 24 member boards.1 MOC is designed to provide a comprehensive approach to physician lifelong learning, self-assessment, and quality improvement through its 4-part framework and alignment with the core competencies adopted by American Board of Medical Specialties and the Accreditation Council for Graduate Medical Education. The American Board of Family Medicine (ABFM) began MOC in 2003, and by 2012, more than 80 000 board-certified family physicians had entered MOC, with 86% meeting all requirements.2 Prior to 2012, the ABFM’s MOC program included conducting at least one practice assessment and structured quality improvement project every 3 years, most often a Performance in Practice Module (PPM). These are similar to offerings by other certifying boards, including Practice Improvement Modules created by the American Board of Internal Medicine that are utilized by the majority of internal medicine physicians.3 These components of MOC build on evidence that audit and feedback can improve care quality.1,4 In 2007, the Centers for Medicare & Medicaid Services (CMS) introduced the Patient Quality Reporting Initiative, which subsequently became the Physician

Quality Reporting System (PQRS). Between 2007 and 2015, physicians participating in PQRS are eligible for a 1.5% bonus on qualifying Medicare payments. The 2014 Physician Fee Schedule Final Rule authorizes use of 2014 PQRS measures to rate physicians on the federal Web site, Physician Compare, in 2015 and will be used in 2016 to financially penalize nonparticipants.5 The ABFM is approved to submit PQRS data to CMS on behalf of its Diplomates using the ABFM Performance in Practice Registry. Between 2008 and 2012, this registry allowed ABFM Diplomates to use the PQRS diabetes module to collect and submit diabetes quality data to the Registry on 30 unique, separate, and distinct type 1 or type 2 diabetes mellitus patients, the majority of whom are Medicare Part B beneficiaries between the ages of 18 and 75 years (the required number was reduced to 20 patients in 2013). The ABFM then submitted the data to CMS. ABFM Diplomates were then given the opportunity to use 1

American Board of Family Medicine, Lexington, KY University of Utah, Salt Lake City, UT


Corresponding Author: Robert L. Phillips, MD, MSPH, American Board of Family Medicine, 1648 McGrathiana Pkwy, Suite 550, Lexington, KY 40511. Email: [email protected]

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American Journal of Medical Quality

Table 1.  Comparisons of Physician Quality Reporting System (PQRS), Performance in the Practice of Medicine (PPM) Modules, and Combined PQRS/PPM Programs.

Sponsoring organization Meets maintenance of certification requirement Meets CMS reporting requirements Payment incentive Peer comparison feedback Quality reporting Quality improvement activity required Number of patients involved

Diabetes PPM





ABFM utilizing CMS data Yes




No Yes To ABFM only Yes

Yes No To ABFM and CMS No

Yes Yes To ABMFM and CMS Yes

10 Pre intervention; 10 post intervention


30 Pre intervention; 10 to 30 post intervention

Abbreviations: ABFM, American Board of Family Medicine; CMS, Centers for Medicare & Medicaid Services.

their PQRS reported data to begin a PPM. In doing so, physicians were not only measuring their care quality, but also conducting a quality improvement activity on at least one of the diabetes quality measures reported via PQRS. See Table 1 for a brief description of these 3 programs. To be clear, a physician choosing to only complete a PQRS diabetes module is committing to doing a quality improvement effort and reporting related quality measures before and after the effort. A physician choosing to only submit PQRS data to CMS via the ABFM registry does not do a quality improvement project; it is strictly a means of fulfilling a CMS reporting option that has implications for public reporting and Medicare payments. PQRS reporting physicians do not get the peer-comparison feedback that a physician doing the PPM would get. Some physicians choose to take advantage of the opportunity to do both, fulfilling MOC and CMS requirements through one effort. The measures reported are the same for both programs, but the dual reporters still have to complete a quality improvement project, report their measures twice, and receive peer comparison feedback. Prior research on PQRS has investigated the time and cost of implementation,6-8 but no studies to the study team’s knowledge have tested whether PQRS participation is associated with improvement in the outcomes it measures. Initial studies of physicians participating in PQRS concluded that the majority felt that it would have little impact on practice quality; however, primary care physicians had a more positive outlook than did surgeons.9 The objective of the present study was to look at the differences in outcomes between participants in the regular ABFM diabetes mellitus PPM, the diabetes mellitus PPM with PQRS (PQRS/PPM), and the diabetes PQRS registry alone. This study reflects a keen interest in understanding whether this alignment is having any differential impact and testing whether quality

improvement and feedback (MOC) add value to quality reporting (PQRS).

Methods Completion of PPM The PPM process resembles a Plan-Do-Study-Act cycle. First, the physician collects data from 10 patients with diabetes who are seen in the office. Questionnaires are administered to the patients to assess knowledge of their health goals and current disease status. After entry of the physician collected data and survey data, the physician is provided a “quality dashboard” showing his or her performance on all 7 diabetes indicators and his or her comparative performance to physicians who completed the PPM previously. Next, physicians select the quality measure that they would like to improve, choosing at least one of the measures. Once the measure(s) is selected, a quality improvement plan is created using at least 2 categories from the Chronic Care Model: self-management support, delivery system design, decision support, clinical information systems, health system, and community resources and policies.8 At least one intervention must be selected within each chosen Chronic Care Model category. The PPM provides many options for interventions, with links to more information and examples. After physicians implement their interventions, they repeat the data collection process on 10 patients and enter the data, and they are provided with pre and post comparisons.

Completion of PQRS For PQRS reporting from 2008 to 2012, CMS required a one-time chart audit of 30 patients. Diplomates completed an online attestation form giving the ABFM

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Phillips et al permission to transmit their data to CMS. Data could be collected using printed templates or recorded from an electronic health record as long as the data were from 30 unique adult Medicare Part B beneficiaries with diabetes mellitus. Approximately 3% of the registry’s participants were randomly selected for audit.

Completion of PQRS/PPM Diplomates wanting to do both MOC and PQRS reporting could elect to do so in one of 2 ways. The first was by conducting the PQRS chart audit, then completing the quality improvement activity by following the diabetes PPM protocol, and then the 10-patient post chart audit. The second option was to perform the PQRS chart audit and the quality improvement activity and then report a second PQRS chart audit in the following year, allowing the physician to receive PQRS credit for both years. These 2 options were combined into a PQRS/PPM group for analysis.

Quality Measures There were 12 measures compared between the PPM and PQRS: (1) Was the patient’s hemoglobin A1c checked in the past 12 months for the PQRS/PPM and 6 months for the diabetes PPM; (2) if checked, was the hemoglobin A1c ≤9%; (3) was the patient’s low-density lipoprotein (LDL) checked in the last 12 months; (4) if checked, was the LDL

Maintenance of Certification, Medicare Quality Reporting, and Quality of Diabetes Care.

Aligning maintenance of certification with quality reporting may ease reporting burden, but the impact on quality is uncertain. This study compared ch...
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