AAMC Reporter: October 2008

CMS Expands Pay-For-Reporting Initiative

The Centers for Medicare and Medicaid Services (CMS) recently provided their first bonus payments to physicians who reported quality performance data under the voluntary Physician Quality Reporting Initiative (PQRI). The PQRI, which is now undergoing expansion, is part of a broad and politically popular set of CMS initiatives—known generally as pay-for-reporting and pay-for- performance—designed to encourage more quality measures in inpatient and outpatient settings.

The CMS completed its first PQRI cycle in July. The program rewards eligible health care professionals for their reporting efforts with a bonus of up to 1.5 percent of their total Medicare reimbursements from July 1-Dec. 31, 2007. To qualify for the 2007 PQRI Medicare bonus, providers chose from among 74 measures, such as high blood pressure control among diabetics. Participants used special codes on Medicare claim forms to indicate which measures they completed. CMS then calculated how often the professionals reported each measure. In order to receive the bonus, at least three selected measures had to be reported at least 80 percent of the time.

According to data from the Faculty Practice Solutions Center, a joint venture between the AAMC and the University HealthSystem Consortium, 13 percent of eligible faculty practice professionals participated in the 2007 PQRI. Nationally, CMS officials stated that approximately half of all program participants met the 80 percent threshold for receiving bonus payments.

Some health care providers said that certain details of the program caused difficulty and may have actually prevented others from participating in the first place. Some officials recommended that CMS refine the program and educate those who did not qualify for the bonus.

"There were some issues that made reporting by physicians and other eligible practitioners difficult," said Mary Patton, AAMC's health care affairs senior specialist. "But ultimately, we are supportive of being transparent in the care our physicians provide and will continue to work with CMS to support physician participation by improving the data collection and submission processes."

Finding ways to maximize participation and optimize the program's effectiveness is particularly important, Patton said, because CMS and Congress have indicated that they intend to begin publishing the names of physicians who successfully report measures under the PQRI. Furthermore, pay-for-reporting and pay-forperformance initiatives enjoy support from both presidential candidates and many lawmakers, and will likely gain more prominence in the American health care debate.

"There is broad support for physician reporting— people feel this is a way to keep providers accountable for the care they provide, and improve patient outcomes," Patton said. "As these programs are expanded in the future it is important that we work out any implementation issues now, while we're still in the early stages."

Some of these obstacles arose when participating health professionals began integrating new, PQRI-specific data collection and reporting systems into their practice settings. Because reporting on the quality measures meant an extra step in the claims process, claims submissions slowed substantially in some cases and even affected practice cash flows, Patton said. Rex McCallum, M.D., associate medical director at Duke University School of Medicine's private diagnostic clinic, estimated that the average cost of implementing a reporting system for a Duke surgical department was about $50,000. Even though CMS offered the bonus, they arrived several months after the reporting period ended, while the implementation expenses occurred up front.

There were also issues related to the 74 quality measures themselves.McCallum said that physicians in certain fields, such as infectious diseases, had few relevant measures to choose from. Some doctors felt that certain measures contained ambiguous wording that could have led to reporting mistakes. Jerry Stonemetz, M.D., a billing and compliance officer in Johns Hopkins Medical Institute's anesthesia department, said it was unclear whether providers should be reporting on the measures when they were performed on patients slightly outside stated parameters. Partly for this reason, most Hopkins departments opted out of participating in the 2007 PQRI, Stonemetz said.

Starting this year, CMS will streamline its reporting system and reduce reimbursement turnaround times by accepting data through centralized registries; in 2009, the agency will accept information from electronic health records. To further encourage participation and better offset the costs or lost revenue associated with reporting, the recently enactedMedicare Improvements for Patients and Providers Act of 2008 increased the bonus payment from 1.5 percent to 2 percent, starting in 2009. Physicians can expect more quality measures in the future, Patton said. CMS increased the 2008 measures from 74 to 119, and 174 are proposed for 2009.

The CMS changes, and the fact that practices have now had time to adjust their procedures for PQRI,may mean higher participation levels.McCallum is predicting an increase among Duke faculty; at Hopkins, Stonemetz estimated that 50 percent of departments are signing up for 2008 reporting—not for monetary reasons, but to publicly demonstrate the quality of their care.

"It takes X amount of money to capture the measures for a 1.5 percent reimbursement," Stonemetz said. "But the ability to show we are in the 90 percentile is priceless."

For 2010, CMS is adding physician group reporting, in which an entire practice reports their aggregated quality measures. Some places, like the University of Michigan Medical School, are already participating in group reporting test programs.

"The number of patients is too small at the individual physician level to make determinations," said David Spahlinger, M.D., executive director of the school's faculty group practice. "The reality is that a patient is cared for by multiple different touches, so we should measure those systems of care." 

—By Elissa Fuchs