Doctors still can try for bonuses as Medicare expands quality reporting

Washington -- It's not too late for physicians to begin participating in Medicare's pay-for-reporting program. The Centers for Medicare & Medicaid Services has implemented a number of changes aimed at enticing more doctors to give the program valuable quality information while striving for a 1.5% bonus on their Medicare payments.

The Physician Quality Reporting Initiative was in effect for only the last six months of 2007 but runs for the entire year in 2008.

In addition, the list of quality measures has expanded from 74 to 119. CMS has added two structural measures -- one that rewards the use of electronic medical records and the other for e-prescribing.

Although nearly half of the year is already over, physicians who have not yet participated in the initiative still can qualify for a full-year bonus. If a physician is able to report at least three measures for at least 80% of the patients to whom those measures apply, he or she could still receive the 1.5% lump-sum bonus on all of their allowable charges for the year.

Some of the quality measures, such as blood pressure control for diabetes mellitus patients, need only be reported once per applicable patient during the entire reporting period, instead of every time the associated test or procedure is given. A doctor therefore could hit the 80% mark even if the physician missed an opportunity to report on patients earlier in the year.

New options for doctors

For physicians who may have missed their chance for a full-year bonus, however, CMS also is offering a six-month reporting period that starts July 1. For that option, participating doctors can't report individual measures but instead must report a single measures group pertaining to a particular chronic condition.

A physician who sees a significant number of diabetes mellitus patients, for example, might want to consider reporting on the diabetes measures group. It contains measures associated with five tests: hemoglobin A1c, low density lipoprotein, blood pressure, urine and eyes.

In addition to diabetes, the measures groups cover end-stage renal disease, chronic kidney disease and preventive care.

CMS also is offering another reporting option that could make the 2008 PQRI attractive to a wider array of physicians. The agency will allow doctors to report individual measures or measures groups through approved clinical quality registries instead of using special CPT-II codes and temporary G-codes on claims.

Many physicians already give quality data to registries, such as the National Cardiovascular Data Registry and the ones maintained by the Society of Thoracic Surgeons and the American Osteopathic Assn. As long as the individual measures or measures groups sent to the registry meet the same minimum requirements as those reported via Medicare claims, the participating physician could be eligible for either a half-year or full-year bonus.

"If a physician is already reporting information that pertains to PQRI measures, it would be certainly less burdensome to the physicians if we would accept the information from the registries, rather than require the physicians to duplicate submission of data by not only sending it to the registry but also sending it to us in claims," said Michael T. Rapp, MD, director of the CMS quality measurement and health assessment group. The agency will announce the qualified registries on Aug. 31 and will begin accepting report submissions in December.

AMA help for participants

The American Medical Association is urging physicians who are considering participating in the 2008 PQRI to review carefully the instructions and frequently asked questions posted on the CMS Web site for the initiative (link).

The agency no longer can reduce the 1.5% bonus for a physician if it determines that the doctor chose measures that applied to relatively too few patients in his or her practice. CMS reduced bonuses in this way for the 2007 program. The agency will, however, deny outright the extra payment for doctors who do not meet the minimum reporting requirements. This would mean that the six months to a year of extra administrative work the practice invested for PQRI would reap no financial benefit.

To help physicians navigate the program and make sure that they do not fall short, the AMA has posted a set of tools on its PQRI Web site (link). For each quality measure, the Association provides a detailed description, code specifications that identify eligible patients, and a data collection sheet to help physicians and staffers compile the necessary claims information.

The AMA produced the information in collaboration with CMS, Mathematica Policy Research Inc., and the National Committee for Quality Assurance. Many of the PQRI measures were developed by the AMA-convened Physician Consortium for Performance Improvement with the help of NCQA and medical specialty societies.

Administration officials hope that many more physicians will decide to try for the bonus and enhance Medicare's quality efforts. "We're eager to encourage more physicians and other eligible professionals to participate in the program, and that is the reason for these various options," Dr. Rapp said.

Last year, only about 16% of physicians and other eligible health professionals submitted at least one quality code on their claims, CMS said. Only slightly more than half of those doctors reported enough to be eligible for a bonus. The agency will distribute the extra pay in mid-July.

Although some observers said the participation rate was not very high last year, Medicare officials were cheered by what they saw as good representation by many different types of physicians and medical practices, said CMS Deputy Administrator Herb B. Kuhn at a May 8 congressional hearing. He noted that the 2007 program had never been attempted before and ran for only six months.

More doctors eventually will come around to the promise of the pay-for-reporting program, Kuhn predicted. "Physicians are sometimes slow adopters."