Last chance for quality reporting before Medicare penalty kicks in

Washington Hundreds of thousands of physicians are participating in Medicare's physician quality reporting system and are on track to stop a 1.5% payment penalty by submitting valid quality measure codes in 2013. However, nearly 700,000 doctors and other health professionals had not successfully reported during the most recent year for which results are available — a shortfall that will mean pay reductions for those physicians if they do not change course this year.

A recent Centers for Medicare & Medicaid Services analysis of PQRS and electronic prescribing initiatives in Medicare showed a higher number of physicians engaged in quality reporting activity in 2011 than in the previous year. More than 320,000 eligible health care professionals submitted PQRS data, compared with about 100,000 during the inaugural 2007 reporting period. At least 200,000 more would need to participate in PQRS in 2013 to achieve a CMS goal of at least half of all health professionals avoiding the first penalty, which will apply to 2015 payment rates.

To prevent the penalty, a physician needs to send a valid quality measure code at least once in 2013. The 2011 reporting experience analysis showed that 29% of eligible professionals, up from 15% in 2007, had achieved that minimum threshold for participation.

CMS is working with physicians and organized medicine groups to educate them about what is required and encourage reporting before penalties are assessed, said Kate Goodrich, acting director of the quality measurement and health assessment group in the CMS Center for Clinical Standards and Quality. The agency is attempting to make improvements, such as aligning its quality initiatives by 2014, and continuing several outreach programs to doctors advising them how to stop penalties. The Medicare agency also plans to use new administrative powers that would consider quality reporting activity outside of the CMS program as another way to stop the cut.

“We recognize that the program is not burden-free, but we encourage [physicians] to report and give us feedback on how to make the program better,” Goodrich said.

A larger percentage of physicians reporting PQRS data to CMS in 2011 earned incentive payments than in previous years, according to the trends document. Eight out of 10 participants received bonuses worth an average of $1,059 per individual and $9,863 per practice. Incentives represented 1% of a physician or professional's Medicare charges for the year. CMS paid $261.7 million in PQRS bonuses as well as $285 million for successful participation in its e-prescribing initiative.

Nearly 175,000 individuals were paid an average of $1,912 for reporting paperless prescription transactions during eligible patient encounters. More than 135,000 professionals had their 2012 Medicare payments reduced by 1% for not reporting that they e-prescribed medicine in 2011. However, 544,000 avoided the adjustment by reporting at least 10 e-prescribing encounters by June 2011, by receiving hardship exemptions or by not having enough eligible patient cases.

PQRS alternatives

The only sure way to stop PQRS penalties is through successful participation in the reporting program run by CMS. But that could change for some practices when the agency opts to use new powers to recognize reporting through specialty or regional performance programs.

In January, President Obama signed tax legislation with a provision allowing physicians to meet PQRS requirements when they satisfactorily participate in qualified clinical data registries. Starting in 2014, the law directs Medicare to treat physicians using such registries the same as those successfully submitting PQRS measures.

The policy change is welcomed by the American Medical Association, other physicians and CMS itself. Goodrich said her agency has a favorable view of the provision and is working to implement the authorization.

The AMA recently applauded CMS for requesting feedback from stakeholders about implementing the clinical quality data provision. The AMA urged CMS to balance the goals of allowing physicians to engage in quality reporting, so they can qualify for incentives or prevent penalties, and of eventually moving away from pay-for-reporting initiatives and toward pay-for-performance models. The Association recommended that CMS create a mechanism allowing physicians to meet quality reporting requirements through active participation in “deemed” quality measurement and improvement activities.

For instance, CMS could deem participating in clinical registries operated by medical specialties, medical board certification programs, regional health care quality collaboratives or accreditation programs as meeting the requirement. Quality measures reporting through electronic health record systems and similar activities also could qualify.

“This approach facilitates a more streamlined and efficient process through single data submission that meets CMS quality reporting requirements, while also supporting meaningful quality improvement activities would enable CMS to work effectively with external stakeholders and make it feasible to expand the scope of truly relevant quality data collection, even for very small specialties or patient populations,” the AMA stated in a March 28 letter to CMS. Standards and additional guidance would be needed so physicians and other organizations would know how to qualify, the Association said.

Physician-led collaboration on quality

Several examples of specialty and regional quality improvement programs use quality measures but offer physicians more. Funding from Blue Cross Blue Shield of Michigan, for instance, led to the Michigan Urological Surgery Improvement Collaborative in 2011. The program consists of 29 urology practices and more than 70% of the urologists practicing in Michigan, said David C. Miller, MD, MPH, the program's director and an assistant professor of urology at the University of Michigan. He added that the collaborative is more popular among urologists than PQRS.

“I respect PQRS, but this takes things to another level,” Dr. Miller said.

The collaborative uses a Web-based clinical registry that includes data submitted for patients undergoing prostate biopsies and prostate cancer treatments. Random audits are conducted to ensure quality, and a projectwide database is reviewed to identify missing or incomplete information.

Participation is not limited to Medicare patients. Patients on Medicaid or private insurance and those with no insurance coverage are included on the registry, which had more than 3,000 cases in less than 12 months. And despite its funding, Blue Cross Blue Shield of Michigan reviews aggregated data but does not look at the figures for individual physicians.

The registry and accompanying physician-led education activities should result in the program being deemed as a qualified clinical data registry, Dr. Miller said. The infrastructure facilitates discussion about best practices and evidence-based care, Dr. Miller said. Physicians hold meetings to review data and discuss ways to improve care.

For instance, progress is being made on utilization of bone scans to measure the spread of cancer in low-risk patients. Routine bone scans in men with low-risk prostate cancer should be questioned by patients and physicians, according to the Choosing Wisely initiative and the American Urological Assn.

“We are making progress, and I think we will be leading the way in this area in the state of Michigan,” Dr. Miller said.