Practice Economics

Centers for Medicare & Medicaid Services Modify Physician Quality Reporting System


Push for Performance

Only 27% of eligible providers participated in the Physician Quality Reporting System (PQRS) in 2011—roughly 26,500 medical practices and 266,500 medical professionals, according to the Centers for Medicare & Medicaid Services (CMS).

“A lot of physicians have walked away [from PQRS] feeling like there are not sufficient measures for them to be measured against,” says Cheryl Damberg, senior principal researcher at RAND corporation and professor at the Pardee RAND Graduate School in Santa Monica, Calif.

Encouraging more participation from hospitalists has been the goal of the Society of Hospital Medicine (SHM) for the last several years, says Gregory Seymann, MD, SFHM, clinical professor and chief in the division of hospital medicine at University of California San Diego Health Sciences and chair of SHM’s Performance Measurement and Reporting Committee (PMRC).

“The committee has tried to champion it the best we can, making sure the measures that are there and in development meet the needs of the specialty,” Dr. Seymann says.

In just one year, the SHM committee managed to increase hospitalist reportable measures in PQRS from a paltry 11—half of which were only for stroke patients—to 21, which now includes things like diabetes exams, osteoporosis management, documentation of current medications, and community-acquired pneumonia treatment.

Only 27% of eligible providers participated in PQRS in 2011—roughly 26,500 medical practices and 266,500 medical professionals, according to CMS.

For Comparison’s Sake

For the first couple of phases of PQRS reporting, very few measures were relevant to hospitalists, Dr. Seymann says. The committee worked to ensure that more measures were added and billing codes modified to include those used by the specialty. Hospital medicine is relatively new, not officially recognized by the American Board of Medical Specialties (ABMS), and hospitalists serve a unique role. Most hospitalists are in internal medicine, family medicine, or pediatrics, but they aren’t doing what the average primary care doctor does, like referral for breast cancer or colon cancer screening, Dr. Seymann adds. Additionally, they aren’t always the provider performing specific cardiac or neurological care.

Hospitalists’ patients usually are in the hospital because they are sick. They may have chronic disease or more complex medical needs (e.g. osteoporosis-related hip fracture) than the average population seen by a non-hospitalist PCP.

If hospitalists are compared to other PCPs, as is the plan in the Physician Value-Based Payment Modifier, it “looks like our patients are dying a lot more frequently, we’re spending a lot of money, and we’re not doing primary care,” Dr. Seymann explains.

New Brand, New Push

PQRS is not new; it is the rebranding of CMS’ Physician Quality Reporting Initiative (PQRI), launched in 2006. But changes to the program are part of a national push to improve healthcare quality and patient care while reimbursing for performance on outcome- and process-based measures instead of simply for the volume of services provided. Each year, CMS updates PQRS rules.

This year is the last one in which providers will receive a bonus for reporting through PQRS. Beginning next year, practitioners that don’t meet the reporting requirements for 2013 will incur a 1.5% penalty—with additional penalties for physicians in groups of 100 or more from the value-based payment modifier. This year also serves as the performance year for 2016, when a 2% penalty for insufficient reporting will be assessed.

In early December 2013, the Centers for Medicare & Medicaid Services (CMS) published the 2014 Physician Fee Schedule and, with it, the final rules for the PQRS. Although many physicians and specialist groups believed the measures included in PQRS in previous years were too limited, CMS has added the additional reporting methodology of qualified clinical data registries (QCDR), which can include measures outside of the PQRS—a marked shift from previous policies.

The rule change, Damberg says, should take some energy out of the discussion surrounding the program and allow more physicians to participate.

“From CMS’ perspective, they want doctors delivering the recommended care and they want doctors to be able to report it out easily,” Damberg says.

Moving Forward

In 2014, providers can submit measures through the new QCDR option, or submit PQRS-identified measures through a Medicare qualified registry, through electronic health records, through the group practice reporting option (GPRO), and through claims-based reporting (though this last option is expected to be phased out over time).

Registries themselves are not new, but they can cost millions of dollars to establish and as much as a million a year to maintain. They typically contain more clinical depth and specificity than claims data, and numerous studies show the use of registries leads to improved patient outcomes.

“We don’t know how many [existing] registries are going to qualify to become these qualified clinical data registries,” says Tom Granatir, senior vice president for health policy and external relations at ABMS. “It’s going to take some time for these registries to evolve.”

Qualified clinical data registries must be in operation for at least one year to be eligible for certification by Medicare. They must include performance data from other payers beyond Medicare. Not only must QCDRs be capable of capturing and sending data, they must also provide national benchmarks to those who submit and must report back at least four times per year.

Granatir believes the QCDR rule, which allows QCDR’s to report measures beyond those included in the PQRS program, will help increase participation and will lead to more practice-based measures, but he fears it may exclude some important nuances of day-to-day patient care.

“The whole point [of quality measure reporting] is to create more public transparency…but if you have measures that are not relevant to what is actually done in practices, then it’s not a useful dataset,” he says.

Ideally, Damberg says, PQRS and other performance measures should enable physicians to do what they do better.

“I think this is really going to raise the stakes for [hospitalists] if they want to control their destiny,” Damberg says. “I think they have to get really engaged in this game and take a pro-active role in looking at where the quality gaps are and how can they better benefit patients. That’s the ultimate goal.”

Kelly April Tyrrell is a freelance writer in Wilmington, Del.

Next Article:

   Comments ()