Medicare physician quality reporting: Tale of the tape

Unless trends change significantly in 2013, the key determinants of whether a particular physician will be able to avoid a Medicare pay-for-reporting penalty are his or her specialty and the state in which the doctor practices.

These demographics are not the only factors of success in Medicare's physician quality reporting system. But prior years of experience in the initiative, including the most recent year for which data are available, indicate that location and specialty are good indicators of the likelihood of compliance with a program that starts lowering pay by 1.5% in 2015 for doctors who don't participate in 2013.

“Once we understand the rules, we are pretty good at playing by them,” said Lee Hilborne, MD, a professor of pathology and laboratory medicine at the David Geffen School of Medicine at the University of California, Los Angeles.

Pathologists have done relatively well in PQRS. The latest trends report from the Centers for Medicare & Medicaid Services showed that 63% of pathologists eligible for PQRS had submitted quality data codes in 2011. The specialty was just behind emergency medicine, which had a participation rate of 67%.

Wisconsin, a state with large health systems such as the Marshfield Clinic and Dean Medical System, had the top rate in the nation of physicians submitting PQRS data, at 39%. Smaller practices also have opportunities to report PQRS measures through a registry system that partners with the Wisconsin Medical Society, said Nancy Nankivil, the society's chief strategy officer.

“We're very rich in Wisconsin as a measurement environment, because of our focus on quality and resource use among the systems and in our state overall,” Nankivil said.

While some physicians are having measured success in PQRS, others find that the program does not fit well into their practices. Congress created PQRS, and physicians first reported quality measures on claims for Medicare services in 2007. Doctors and other health professionals have earned millions in bonuses from the program, but in 2015 the incentives will be replaced with penalties for physicians who don't report.

The 2015 penalty will be based on PQRS participation in 2013. So if an eligible physician does not report at least one PQRS measure, the minimum threshold for participation this year, his or her pay rates will be cut by 1.5% in two years' time.

The American Medical Association, along with state and specialty societies, strongly have opposed the Medicare penalties. Thousands of physicians were penalized in 2012 and 2013 under a separate Medicare electronic prescribing initiative. Noncompliant physicians also face e-prescribing penalties in 2014 and additional reductions if they do not meet meaningful use requirements for electronic health record systems by 2014. That EHR penalty takes effect in 2015, too.

Physicians have complained that the various programs have not been aligned with one another — requiring them, for example, to report the same information twice in the PQRS and EHR programs. CMS is trying to align these programs better, and officials have said that, starting in 2014, physicians probably will be required to report quality information just once.

“Further aligning reporting requirements across and within the multiple federal performance programs will help improve patient access to care and minimize the aggregate financial and administrative blows to physician practices as they grapple with rising practice costs and physician payments that are only 2% higher than they were in 2001,” the AMA stated in a June 14 letter to Dept. of Health and Human Services Secretary Kathleen Sebelius.

Although there are numerous PQRS success stories, a majority of physicians have not bothered with the pay-for-reporting program while it has been in the bonus phase, according to the CMS 2011 Reporting Experience report. About 641,000 physicians were eligible for the PQRS program, but only 205,000 went through the process to submit quality data for any measure encounter with a patient in 2011. Of those physicians, only 168,000 met the minimum criteria to earn bonuses, which averaged about $1,260.

A disconnect among specialties

There is general agreement in medicine that the PQRS program is a better fit for some physicians and practices than others, doctors and organized medicine groups said.

A basic illustration is measure No. 124, which a physician could report to signal use of an EHR during an eligible patient encounter. Nearly 780,000 health professionals were eligible for the measure in 2011, but only a portion of those had EHRs in the first place (measure No. 124 since has been removed from the list because of the EHR meaningful use incentive program).

Other popular measures, such as those indicating influenza and pneumonia vaccination screenings, appear to apply more to primary care physicians seeing patients during evaluation and management visits. Primary care physicians participate at a slightly higher rate compared with other specialists, who can struggle to find their niche.

“The whole program is a reasonable incentive for E&M-based practices,” said William Wooden, MD, a plastic surgeon and a professor of surgery at Indiana University School of Medicine. Nearly 10% of plastic surgeons participated in PQRS in 2011, but Dr. Wooden said he does not report measures because he does not meet eligibility criteria.

Plastic surgeons had worked to get a measure included on the PQRS list. Measure No. 186 could be reported for chronic wound care when a patient with a venous ulcer is prescribed compression therapy during the PQRS reporting period. CMS data show that 181 eligible physicians reported that measure in 2011, but agency officials scrapped it for the 2013 reporting period because it was not endorsed by the National Quality Forum.

Physicians in small states also lag when it comes to participating in PQRS. Four of the five states with the lowest rates of participation also are the least populated.

Keys to PQRS success

In the early phases of PQRS, pathologists had worked to help draft process measures for quality programs, Dr. Hilborne said. Many pathologists believe that a practice cannot improve on what it does not measure, so they have helped develop measures to follow clinical guidelines, he added. The top-reported measures among pathologists are specific to the specialty and involve breast cancer and colorectal cancer resection pathology.

Emergency physicians frequently reported quality measures related to electrocardiograms and community-acquired pneumonia, the CMS report found. The specialty itself is driven by such data, said Mark Reiter, MD, vice president of the American Academy of Emergency Medicine and CEO of Emergency Excellence in Brentwood, Tenn. Its physicians are comfortable measuring and reporting data.

“It's in compensation arrangements, and metrics are used for incentives,” he said. “A lot of it is not new in emergency medicine.”

In addition, emergency medicine physicians often use third-party billing companies that can submit quality measurement data to CMS on behalf of thousands of physicians, Dr. Reiter said, making the process of compliance less labor-intensive for physicians.

Availability of quality reporting measures specific to a specialty, however, has not always led to interest in PQRS. There are eight psychiatric-specific measures and a handful of general practice measures pertinent to psychiatrists, said Jennifer Dart, a spokeswoman for the American Psychiatric Assn. But only 3% of eligible psychiatrists participated in the program in 2011.

“Psychiatrists have relatively small Medicare patient populations and often work in solo/small practice settings that lack the necessary administrative support to allow for participation,” Dart wrote in an email. “Additionally, many don't have EHRs, so they can't take advantage of participating electronically.”

Furthermore, many physicians struggle to maintain private practices in a changing health system, said M. Elizabeth Sandel, MD, a past president of the American Academy of Physical Medicine and Rehabilitation. Physiatrists in private practice are trying to keep up, she said. The specialty scored a 12% participation rate in 2011.

The vast majority of PQRS measures do not fit within the scope of practice for a physician practicing physical medicine and rehabilitation, and the same can be said for other specialties, Dr. Sandel said. However, she said physiatrists and rehab specialists are not giving up, instead looking to find a way to develop measures to capture accurately the quality services the specialty provides — and boost PQRS participation.

“A lot of the current measures don't demonstrate the impact our specialty has on patient care,” Dr. Sandel said. “As we develop measures that relate to our specialty, we'll put them forward and get them endorsed.”