Medicare PQRS: Quality reporting or else

Physicians who participate in Medicare can consider 2012 to be the last year to practice reporting quality measures to the government before the exercise truly becomes real. Doctors who have not mastered the Medicare physician quality reporting system by the end of this year might find themselves locked into a lower Medicare pay rate a few years down the road.

The quality reporting program has been optional for physicians since its introduction in 2007, and technically it will remain voluntary. But starting in 2013, physicians who don't report enough quality measures will not only forgo a bonus but also see an across-the-board cut in Medicare pay for 2015.

If the history of Medicare's physician quality reporting system is any indication, many physicians could be exposed to the penalty, which starts at 1.5% for 2015 and increases to 2% for 2016 and beyond. Participation in the quality program has been lackluster, according to the latest Centers for Medicare & Medicaid Services report. Only about one in five physicians and other eligible professionals sent quality data to Medicare in 2009, and of those, only slightly more than half did a satisfactory enough job to earn a bonus.

A separate Medicare value-based purchasing program has the potential to decrease some physicians' pay even more starting in 2015, also based on 2013 reporting. The PQRS is a pay-for-reporting program, but in an effort to move Medicare toward actual pay-for-performance, Congress authorized CMS also to use PQRS quality data and cost information from claims to make additional payment adjustments to selected physicians. That payment modifier will reduce pay for some doctors to reward other physicians who are deemed to provide higher-quality care at a lower cost relative to their peers.

The situation has stoked organized medicine opposition to CMS handling of the programs, which join similarly structured initiatives promoting electronic medical records and electronic prescribing. Physician organizations complain that doctors are subject to multiple, confusing requirements, and they say CMS is jumping the gun by holding reporting periods years before pay adjustments are made.

The American Medical Association is one of the groups opposing the CMS proposal for the pay-for-performance modifier and is fighting for the removal of all PQRS penalties, said AMA President Peter W. Carmel, MD. The Association objects to linking the 2015 penalties to 2013 performance, but it also has concerns about how CMS is administering all of the quality initiatives.

"Under current CMS rules, physicians must meet separate requirements for the e-prescribing, PQRS, [EMR] incentive and value-based modifier programs," Dr. Carmel said. "These programs overlap, leaving physicians with unwarranted penalties for deciding to participate in one program over the other."

CMS had considered using quality reporting in 2014 and 2015 to determine pay-cut recipients, but the agency concluded that basing the 2015 penalty on reporting during any year later than 2013 was not operationally feasible.

Physicians also will be flying blind next year when it comes to the value-based purchasing modifier. The modifier methodology will not be finalized until November 2013. That means physicians for the first year will have no way of knowing which doctors will be selected, and on what quality and cost standards they will be judged.

But doctors have had enough time to prepare for the value-based purchasing program even though the final details have yet to be determined, CMS says in its latest Medicare fee schedule. "We strongly encourage physicians to participate in the physician quality reporting system and the [EMR] incentive program sooner rather than later and to choose to report quality-of-care measures that best reflect their practice and patient population."

Illinois State Medical Society President Wayne V. Polek, MD, said any effort to penalize doctors more is inappropriate when they already face Medicare pay cuts nearing 30% under the sustainable growth rate formula. Uncertainty about Medicare payments has weighed heavily on physicians considering investing time and money into complying with new Medicare quality initiatives, he said.

"The government is talking out of both sides of its mouth," Dr. Polek said. "They can't fix the SGR for a dozen years, and they wonder why doctors don't want to participate."

Unaware and uneasy

The Medicare physician quality reporting system requires doctors to report certain activities or data during specific patient encounters. For instance, one diabetes measure requires a doctor to report an eligible patient's most recent hemoglobin A1c level as greater than 9%, between 7% and 9%, or less than 7%. The physician also can indicate that a patient's level has not been measured for 12 months.

After the figures are recorded, physicians can use special codes on claims to report them. Other options for sending data include using third-party registry systems or EMRs that have the measures integrated.

Once CMS has the information, it's up to program officials to determine if it's enough. Physicians must report three or more individual measures during at least 80% of eligible patient encounters. Doctors who fail to report enough often will find out long after the fact that they missed the threshold.

Part of the problem is that, even at the start of the final penalty-free year for PQRS reporting, many physician practices still don't know about it. "I don't think awareness is very high," said Bruce Bagley, MD, the medical director for quality improvement for the American Academy of Family Physicians.

For practices that do know about it, full compliance for bonuses has been elusive. The incentive for completing the program in the 2012 reporting year would be equal to 0.5% of a physician's total Medicare charges for the year, paid as a lump-sum bonus. Doctors who take part in a maintenance-of-certification program can bump that incentive up to 1%. Federal law requires CMS to stop offering bonuses after the 2014 reporting year, at which point only penalties will be in play.

Leslie Spry, MD, and his partners at Lincoln (Neb.) Nephrology & Hypertension have reported quality measures since January 2008. However, they did not receive notice of their success for that first reporting year until the fall of 2009.

"You have no idea if you were doing it right or not," Dr. Spry said. "A few of my partners didn't quite do it right, so we didn't get all the money we could have."

CMS expects to start providing interim feedback reports to eligible professionals this summer so they can get an earlier sense of how they are doing. Those reports would be based on claims for dates of service between Jan. 1 and March 31.

Although the program requires physicians to submit data on only three measures to qualify, Dr. Spry chose to cover his bases by reporting nine of 10 individual quality measures. His office staff designed forms with checkboxes for measures related to diabetes, heart disease and kidney disease care.

"I try to do as many as possible and hope at least three of them would turn out OK," said Dr. Spry, who ended up reporting all nine of the measures successfully.

Ingrained resistance

Others have not been so successful, and physician confidence in Medicare quality incentive programs is weak right now, said Joel Shalowitz, MD, clinical professor of health industry management at Northwestern University and president of The Medical Care Group in Chicago.

A few years ago, Dr. Shalowitz talked to his primary care group about PQRS. Doctors asked about the extra work involved and the potential reward at the end. They each could receive a relatively small bonus, he said, but they would not be paid until 18 months later. The group decided to hold off.

"It was a big disaster," he said. "We're glad we didn't participate."

Success rates among participants have struggled to get much higher than 50%. Final data on participation during the 2010 program year will not be available until late February, said CMS spokesman Joseph Kuchler. "However, I can tell you from a draft I saw that the numbers of successful participants and the incentives issued continue to rise."

Dr. Shalowitz ascribed the low participation and success rates to the complexity of the PQRS. His medical group is installing an EMR, which would help compile quality data for transmission to CMS. But until then, the practice has decided that the process is too labor-intensive for physicians and office staff to accomplish.

Dr. Polek's anesthesia group has reported quality measures since 2008. He said he has been successful reporting measures tied to quality efforts he has done all along, such as timing antibiotics for certain surgeries. But he worries about CMS moving to rely on data points that physicians can't control. A physician charged with tackling obesity rates, for instance, can advise patients to exercise and diet, but it is the patients' responsibility to act.

Last chance for warm-ups

Physicians who start participating in the PQRS now would have more latitude to experiment by selecting quality measures and determining how best to send them to CMS, Dr. Shalowitz said. Doctors can participate in 2012 without being penalized for a reporting mistake.

It will get harder. "There will be firm requirements for reporting conditions, and more and more will be required to avoid being penalized," he said.

Doctors who have not started quality reporting should consider finding a registry-based reporting option for submitting data, Dr. Bagley said. Claims-based reporting can be too cumbersome for some practices, but a reporting registry can be more efficient and give faster feedback.

"If this is the way we have to go anyway, this is an easy way to get your toe in the water," Dr. Bagley said.

He recommended that practices use a registry to report one of 22 measure groups, each containing four to 10 quality measures. CMS publishes a list of approved registries on its website. Most cost a couple of hundred dollars per doctor.

Measure groups cover such areas as diabetes mellitus, preventive care, heart failure and hypertension. Reporting a measure group requires the physician to send quality data for 30 patients, taking the guesswork out of whether the doctor met an 80% threshold.

"It puts you on the road to consistent quality improvement internally," Dr. Bagley said. "No matter who measures you, you'll be better."