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The PQRI is a voluntary Medicare quality reporting program that offers financial incentives for eligible healthcare professionals who participate. Those who successfully report on a designated set of quality measures for services paid under the Medicare physician fee schedule may earn a bonus payment of up to 1.5 percent of their total charges for all Medicare-provided services during the specified period. A major concern with the PQRI is that it may do little to actually improve quality in patient care.
Struggling to make sense of this poorly structured program, the Centers for Medicare and Medicaid Services only recently began to issue program instructions for 2007. The CMS released the following details as of April 2007:
Eligibility — Professionals who are paid under the Medicare physician fee schedule, including physicians, chiropractors, physician assistants and others, are eligible to participate. Furthermore, all Medicare-enrolled eligible professionals may participate, regardless of whether they have accepted assignment on all Medicare claims.
Quality Measures — The 2007 PQRI includes 74 quality measures, which are posted on the CMS Web site. The Web site also includes measure specifications, which describe when each measure is reportable and which quality codes to report. Measures are not specialty specific, and physicians may report on any measure that is applicable to the services he or she provides, although a number of measures, shown in Figure 1, are applicable to neurosurgery.
Reporting — The reporting period is from July 1 through Dec. 31, 2007. There is no special form or process that physicians must go through to register for the PQRI program. Quality data simply will be collected through claims-based reporting, and participants become eligible as soon as they start submitting quality codes with their Medicare claims. Quality codes must be submitted concurrently with the claim for the associated service and may be reported on paper or electronic claims. In order to analyze data at the individual level, the CMS will require physicians to use a National Provider Identifier on all claims.
Determination of Successful Reporting — Eligibility for the bonus payment is based on meeting certain reporting requirements. Successful reporting is defined as reporting a quality measure in 80 percent of the cases in which the professional had the opportunity to report those codes. When no more than three measures are applicable to an individual physician’s patient case mix, each measure must be reported in at least 80 percent of the applicable cases. When four or more measures are applicable, the 80 percent threshold must be met on at least three of the measures.
Bonus Payment — Successful reporters will receive a bonus payment, subject to a cap, equal to 1.5 percent of total allowed charges for all services billed under the Medicare physician fee schedule during the six-month reporting period. A single, consolidated bonus payment will be provided in mid-2008 and the CMS will distribute the bonus payments to the holder of the taxpayer identification number for disbursement among the eligible professionals. While the precise amount of the bonus payment will depend on the individual physician’s Medicare practice, it is anticipated that neurosurgeons will receive between $500 and $2,000 for participating in the program.
Validation — The CMS is required to validate whether all measures applicable to a professional have been reported. Using sampling, the CMS will focus on those who report on fewer than three measures. The agency is in the process of developing an informal inquiry process for those who wish to appeal a finding that the physician is not eligible to receive some or all of the bonus payment.
Feedback — In 2008, the CMS will provide participants with a single, confidential report that includes their performance data. Quality data reported by participants in 2007 will not be publicly reported.
PQRI Participation Requires Careful Evaluation
Organized neurosurgery enthusiastically supports programs that are truly designed
to improve the quality of surgical care. However, at present it appears that
the PQRI does not meet this test. Most physicians have no experience in quality
reporting and do not have the necessary health information technology and administrative
infrastructures in place to participate in such a system. Furthermore, the
small financial incentive provided in 2007 is unlikely to generate enough money
to cover the costs of participating in the program. For instance, a large academic
medical center with more than 600 physicians on the medical staff estimated
that participating in the PQRI would result in a $700 bonus per physician,
which is not nearly enough money to cover the time and cost of reporting. Neurosurgeons
should carefully evaluate the PQRI program costs and benefits, as shown in
Figure 2, to determine whether the benefits of participation will outweigh
the administrative costs and complexity of preparing their practices for the
program.
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However, neurosurgeons also should be aware that physician quality reporting likely is here to stay. There are an estimated 130 pay-for-performance programs nationwide and more than one-half of the nation’s HMOs currently use P4P in contracts with hospitals and doctors. Federal law requires Medicare to implement a mandatory hospital P4P program by 2009, and a recent Government Accountability Office study found physician outliers who are overly expensive and inefficient, thereby fueling policymakers’ desire to incorporate quality and cost measures into the Medicare physician payment system. The PQRI program therefore may help neurosurgeons familiarize themselves with quality reporting systems before they become a mandatory part of physician practice.
Quality Reporting in 2008 and Beyond
The Tax Relief and Health Care Act of 2006 requires the CMS to implement a
quality reporting program in 2008; however the language is vague and leaves
the CMS with broad authority to design the program as the agency sees fit.
The AANS and the CNS have a number of specific concerns about the new law among
them that there is:
▪ little opportunity for physician input;
▪ no indication of whether this will morph into P4P or whether it will be voluntary or mandatory;
▪ no indication if bonus payments will be available; and
▪ no indication of what measures will be included.
There are two bright spots in this legislation. First, the CMS must establish a mechanism whereby physicians may report quality measures through medical registries. Second, the law established the $1.35 billion Physician Assistance and Quality Initiative Fund, and the CMS may use this money for quality improvement activities or to stabilize the sustainable growth rate and reduce the magnitude of the 2008 physician payment cut.
Sharing similar concerns regarding the 2008 program, the AANS and the CNS, working with the Alliance of Specialty Medicine, drafted legislation that would modify the quality provisions of the Tax Relief and Health Care Act of 2006. Introduced on May 24 by Sens. Benjamin Cardin, D-Md., and Arlen Specter, R-Pa., S. 1519, the Voluntary Medicare Quality Reporting Act of 2007 would:
▪ require that the 2007 quality reporting program be evaluated prior to implementing a permanent program;
▪ defer the implementation date of a permanent program until January 2010;
▪ make clear that the reporting program is voluntary ;
▪ ensure that quality measures go through the AMA’s Physician Consortium for Performance Improvement; and
▪ prohibit the CMS from implementing quality measures outside of an established process.
A similar bill will likely be introduced in the House of Representatives by Reps. Bart Gordon, D-Tenn., and John Shadegg, R-Ariz.
The AANS and the CNS will continue to pressure Congress to reform the sustainable growth rate before physicians are asked to undertake a new commitment of time and resources to report quality measures. They have recommended, among other things, that the CMS use the Physician Assistance and Quality Initiative Fund to help avert the expected 10 percent physician payment cut in 2008 rather than spending these funds on quality reporting bonus payments.
Response to Quality Improvement Trend
Many physicians and their representatives have involved themselves in the
quality improvement trend to shape it from the physician’s perspective.
Key players in the physician quality movement are shown in Figure 3.
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Recognizing that organized neurosurgery cannot just sit on the sidelines, the AANS and the CNS are working through their Washington Committee Quality Improvement Workgroup to participate in a number of quality improvement initiatives. While organized neurosurgery believes that reporting outcomes to registries is the superior way to assess and improve surgical quality, the Quality Improvement Workgroup nevertheless is working with the AMA Physician Consortium for Performance Improvement to develop process measures that are applicable to neurosurgery. One current PCPI initiative is the development of quality measures for spinal stenosis in a cooperative effort by the AANS, the CNS, the North American Spine Society, and the American Academy of Orthopaedic Surgeons.
Recently, the AANS and the CNS provided feedback to the National Committee for Quality Assurance for its Back Pain Recognition Program and will continue to work with the NCQA to further refine the quality measures and data collection tools. The NCQA recently released the 2007 program requirements, which use 16 evidence-based criteria to identify high-quality back pain physicians. Private health plans may require physicians to participate in the “voluntary” program in order to qualify for spine care services reimbursement or bonus payment.
Lastly, the AANS and the CNS are working with the CMS and with other specialty societies to develop standardized data collection and case-adjustment systems that will allow outcomes reporting. Because there already exist registries in which neurosurgeons may participate — the Carotid Artery Revascularization and Endarterectomy Registry and the American College of Surgeons’ National Surgical Quality Improvement Program — and outcomes registries sponsored by the AANS and the CNS may be implemented in the future, in 2008 there may be opportunities for physicians to earn bonuses by reporting to registries. The Quality Improvement Workgroup is working to develop an outcomes registry system that will ultimately allow practicing neurosurgeons to satisfy both ABNS Maintenance of Certification case reporting and Medicare and other third-party payers’ P4P requirements. The CMS has expressed interest in these initiatives, although it has not yet determined how it will incorporate such registry participation into its future quality program.
Developing Meaningful Systems Sparse evidence exists on the efficacy of a P4P program in Medicare. The only thing that researchers seem to agree on is that P4P is complex and that further research is needed. Despite the lack of proof that P4P will improve the quality of care and save healthcare dollars, Congress, the CMS, employers, patients, health plans and others are pressing forward with quality reporting programs. The AANS and the CNS must be active participants in developing reasonable and meaningful quality improvement systems. To sit on the sidelines with our heads in the sand will not make this go away and neurosurgeons will nevertheless be forced to participate in ill-conceived quality programs that do nothing to improve patient care.
Rachel Groman is senior manager of quality improvement and research and Katie Orrico, JD, is director of the AANS/CNS Washington office.
For More Information
■ AANS/CNS Washington Committee Activities, https://www.aans.org/legislative/aans/washington_c.asp
■ 2007 Physician Quality Reporting Initiative, www.cms.hhs.gov/PQRI
■ National Provider Identifier, www.cms.hhs.gov/NationalProvIdentStand/
■ NCQA Back Pain Recognition Program, https://web.ncqa.org/tabid/137/Default.aspx