Medicare pay-for-reporting effort draws fire from frustrated doctors

Washington -- Medicare's flagship Physician Quality Reporting Initiative has left in its wake a sea of annoyed physicians who say the pay-for-reporting program is being poorly managed by an unresponsive administration.

In July, more than a year after nearly 100,000 doctors started reporting quality measures to Medicare for the first time, the Centers for Medicare & Medicaid Services started sending out the first of more than 55,000 bonus checks to those who reported enough measures to qualify in 2007. In August, CMS began allowing participants access to confidential reports to let them know if they achieved the reporting threshold for the measures they chose -- or by how much they fell short. So far, the reviews from doctors on both processes have been largely dismal.

For starters, nearly half of the physicians who tried for a 1.5% bonus failed to get one, prompting doctors who never received the anticipated check to download their reports and find out why. But many who tried to access the documents were defeated by stringent security measures, and some gave up before they could see their performance. Those who did found the data useless in telling them how to improve quality.

If any physician participants were going to qualify for a bonus, William L. Rich III, MD, figured he would. The Falls Church, Va., ophthalmologist was an early and enthusiastic supporter of the pay-for-reporting initiative. He not only persuaded members of his own practice to participate but also helped bring on board many members of his profession through his role as the American Academy of Ophthalmology's medical director of health policy.

That's why Dr. Rich was shocked to find he was not one of the members of his practice who received a check for the 2007 run. He meticulously had researched the minimum three quality measures to report and changed his billing software to send data to Medicare automatically. Still, his feedback showed he reported measures for only about half of applicable patients instead of the required 80%.

"I'm the poster boy for this program, and even I could not manage to get a bonus," he said. He suspects that CMS may have used faulty algorithms that assumed he should have reported more measures than were applicable.

Jeffrey E. Kaufman, MD, a urologist in Santa Ana, Calif., still doesn't know why he didn't qualify. The key section of his confidential feedback document that would tell him the answer contained no data. And he reached this point only after frustrating steps to access the report, a multistage approval process that requires each practice to designate a separate security officer and user group administrator. "You'd think you were getting CIA clearance," he said.

Jeffrey L. Kaufman, MD, a vascular surgeon in Springfield, Mass., is still trying to figure out if he even received a bonus because his practice is in the midst of a reorganization and the check possibly was sent elsewhere. But he cannot track that down until he accesses his report, and so far, the process has stymied him.

The situation is particularly frustrating because of his long history with Medicare, he said. "They know me, and yet they're making me go through all this rigmarole, and I still can't get the data."

Physician practices nationwide have similar gripes with the 2007 round of the Medicare PQRI and complain that CMS has been of little help.

In a survey released Sept. 8 by the Medical Group Management Assn., nearly 93% of practice managers said they had difficulty accessing quality feedback reports. Practices spent an average of five hours obtaining the documents from the CMS Web site. Of those who were successful in downloading the information, nearly 70% experienced no or low satisfaction with the reports in terms of helping to improve quality.

CMS cannot wait 18 months after the program year starts before giving physicians a clue as to whether they are reporting correctly, said William F. Jessee, MD, MGMA's president and CEO. "To truly improve patient care, programs such as PQRI must provide timely, actionable clinical information to physicians. Our data show the program has penalized practices trying to do the right thing for their patients by wrapping them in red tape."

The AMA also called for a much more extensive CMS education campaign, especially given doctors' low success rate. "It is clear from this alarming statistic that there is significant confusion among physicians about how to successfully meet the requirements of the PQRI," said AMA Executive Vice President and CEO Michael D. Maves, MD, MBA.

Preventing an exodus

An official said CMS was sorry doctors were having problems accessing feedback and getting questions answered. "These things ended up being more complicated than thought at first blush," he said, noting this was the first year of a multiyear effort.

Nevertheless, the agency is sure it approved bonuses only for those who legitimately deserved them, the official said. Physicians who expected an award and didn't get one should check with carriers to see if one should have been sent. If not, doctors should review their remittance advice notices to see if all necessary data -- such as quality codes and National Provider Identifiers -- made it to the carriers. No appeals process exists for physicians denied bonuses.

The administration and physicians who are still committed to the quality reporting initiative are now scrambling to urge other doctors not to give up on the PQRI amid the frustrations. Dr. Kaufman, the urologist, said his colleagues are starting to ask why they should bother going through this ordeal when they see such little chances for financial or quality gains.

The fact that doctors are uncovering PQRI's problems late in the game is troublesome because the initiative is ongoing, Dr. Rich said. He has all but given up on qualifying for a bonus in 2008, the first full year of the program, because he hasn't changed tactics from the last half of 2007. Still, he remains confident the process can be fixed before the 2009 cycle, when doctors will be vying for a 2% bonus.

"The percentages had better improve, or this program is in trouble," Dr. Rich said.