Medicolegal Issues

Pay-for-Reporting is Here to Stay


Congress made history in July when it passed legislation that makes Medicare’s voluntary pay-for-reporting program permanent.

The program, the Physician Quality Reporting Initiative, or PQRI, which began in 2007 as a six-month trial and was continued through 2008, rewards physicians who successfully report on specific applicable quality measures with a cash bonus. The new bill, the Medicare Improvement for Patients and Providers Act (MIPPA), extends the Centers for Medicare and Medicaid (CMS) program beyond 2010.

“PQRI is now a permanent program, even though the details have only been provided through 2010,” says Michael Rapp, MD, of the CMS Office of Clinical Standards and Quality.

Here, is a look at PQRI past, present, and future, from a hospitalist’s point of view.

Policy Points

Final IPPS Includes Only Three HACs

CMS will no longer pay a higher DRG rate for three healthcare-acquired conditions (HACs) if those conditions are not present on admission, according to the 2009 inpatient prospective payment system (IPPS) final rule. That’s a significant decrease from the nine the agency initially proposed.

The conditions in this year’s final rule are:

  • Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity;
  • Certain manifestations of poor glycemic control; and
  • Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures.

View the complete final rule online at InpatientPPS/downloads/CMS-1390-F.pdf. The HAC discussion begins on page 171.

House Committee Approves HIT Bill

The “Protecting Records, Optimizing Treatment, and Easing Communication through Healthcare Technology Act of 2008” or PRO(TECH)T Act, passed the House Committee on Energy and Commerce in July.

The bipartisan legislation is intended to strengthen the quality of healthcare, reduce medical errors and costs, and further protect the privacy and security of health information by promoting nationwide adoption of a health information technology (HIT) infrastructure and establishing incentives for doctors, hospitals, insurers, and the government to exchange health information electronically across the country.

Also in July, the House Ways and Means Health Subcommittee had a hearing on HIT and privacy protections, and Subcommittee Chair Pete Stark (D-Calif.) announced plans to introduce his own bill.

Pay-for-Performance Pilot Proves Worthwhile

In August, CMS released statistics on that first pay-for-reporting period. During the trial, 101,138 physicians submitted a quality-data code. Of those, 70,207 reported on at least one measure, and 56,722 earned a bonus.

Asked about those numbers, Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La., and chair of SHM’s Performance and Standards Committee, says: “I think the folks at Medicare were pleased with that level of participation. This data helped convince them that the program should be permanent.”

What to Expect in 2009

The PQRI for 2009 is subject to revisions until the 2009 Physician Fee Schedule Final Rule is published sometime around Nov. 1. (Find the latest information on CMS Web site at A number of proposed enhancements make it attractive and important to physicians, Dr. Torcson says.

CMS proposed 175 quality measures for physicians to report on, and MIPPA boosts payment for successful reporting of data on those measures. For 2009 and 2010, physicians who participate in the PQRI can earn an incentive payment of 2% (up from 1.5%) of their total allowed charges for Physician Fee Schedule (PFS) covered professional services.

However, except for a bigger check from CMS, hospitalists who currently report may not see much difference next year. “Overall, for hospitalists, PQRI will look pretty similar to 2007 and 2008,” Dr. Torcson warns. “The bonus is going to increase and the measures will be the same. That means that all of the background and education that SHM has provided on PQRI reporting remains relevant.”

One addition for 2009 is the use of patient registries to avoid claims systems for certain outpatient measures. “I don’t see the registry-reporting option being available to hospitalists in the short term,” Dr. Torcson says, “but it’s worth watching for the future.”

Beginning in 2009 and continuing through the next four years, Medicare also will provide incentive payments to eligible professionals who are successful electronic prescribers. (See the “Public Policy” article on p. 15 of the September 2008 The Hospitalist.) The e-prescribing measure in the 2008 PQRI will be removed for next year and used wholesale for a separate pay-for-reporting initiative pending changes from the Department of Health & Human Services. Unfortunately, none of the 2008 coding specifications for e-prescribing are available for hospitalist reporting.

“A lot of [the PQRI] measures have been created from the perspective of the cottage-industry model of an office-based private practice,” Dr. Torcson explains. “This 2008 (e-prescribing) measure was geared for an office-based physician practice—and the unforeseen consequence of the measure is that it’s not inclusive of patients being discharged from the hospital.”

Where Hospital Medicine Fits

By now, hospitalists should be resigned to the idea that many measures in PQRI don’t apply to their patients. However, SHM continues to work toward more inclusion for hospital-based physicians, by commenting on proposed rules and participating in the National Quality Forum and the American Medical Association’s Physician Consortium for Performance Improvement.

“We have been advocating for including performance measures for care processes, including transitions of care,” Dr. Torcson says. “This will probably come into play more in 2010 than 2009.”

SHM also has submitted comments on the proposed e-prescribing measures. Dr. Torcson says the organization is lobbying to make e-prescribing applicable to all hospital-based physicians, including ER doctors, and for discharged patients. “We want the whole process to harmonize with a comprehensive and safe discharge process that includes medication reconciliation,” he says.

To Report or Not to Report?

Regardless of whether lobbying efforts succeed in making more reporting applicable to hospital medicine, should groups start reporting in 2009? “It’s going to be a tough decision,” Dr. Torcson admits. “There’s a pretty significant investment in time and infrastructure to set this up. For the groups I know, the return on investment was negative.” In other words, PQRI does not pay for itself in a hospital medicine setting.

He says any hospital medicine group that wants to report should have in place a computerized system, and be willing to start slowly. “I’m convinced that it’s going to take an electronic coding/documentation system, as well as designated support staff within the hospital medicine group to pull it off,” he says. “This almost requires a full-time person.”

Dr. Torcson recommends starting with the reporting of three or four measures. “If you’re using a manual process or a homegrown system,” he says, “then the fewer measures the better, in terms of doing PQRI right to reach the 80% threshold.”

If you’re interested in reporting under the 2009 PQRI, go to SHM’s Web site at and type “PQRI 2008” into the advanced search bar. The article, “Information on PQRI 2008,” from May 17, 2007, provides important details about the program, including which measures apply to hospitalists. TH

Jane Jerrard is a medical writer based in Chicago.

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