Round One for PQRI

In December of 2006, the “Tax Relief and Health Care Act” of 2006 was signed, authorizing the Centers for Medicare and Medicaid Services (CMS) to establish a physician quality reporting system. In response, CMS created the Physician Quality Reporting Initiative (PQRI) on July 1, 2007.

Participants were required to report compliance with quality measures deemed relevant to specific diseases. Rheumatologists were involved with five pertaining to osteoporosis and one to falls. Initially, a bonus of 1.5% of total allowed Medicare physician fee schedule services was offered to physicians meeting reporting goals.

“At first blush, these goals were laudable; who can argue against Mom, apple pie, and quality in medical care?” says Herbert Baraf, MD, managing partner at Arthritis and Rheumatism Associates in Washington, D.C. “As we got further along, PQRI became an obedience test to see if you could check off a box to show that you had dealt with a quality measure. It did not matter that you had provided quality care; what mattered was whether physicians could report on parameters that other folks thought indicative of quality.”

One of the goals of the PRQI, according to CMS, is to turn Medicare from “a passive payer into an active purchaser of high-quality care by linking payment to the value of care provided.”¹

“What CMS hopes to get eventually is a group of physicians who report back to the government on how well they are doing,” says David Borenstein, MD, a partner with Dr. Baraf at Arthritis and Rheumatism Associates, treasurer of the ACR, and a TR editorial board member. “To get there, CMS has to get doctors used to the idea that they have to tell CMS something other than what is owed for a visit.”

Data Capture Difficult

Initially, CMS gave physicians an incentive of a 1.5% bonus, rising to 2.0% for 2009. All experts interviewed indicated that they expect to see the bonuses end and a transition to a system where physicians may see payments lowered if they don’t meet reporting requirements.

There are indications that this transition may not be easy. The implementation of the first year of the program drew much criticism from participants. A survey by the Medical Group Management Association (MGMA) found that 25% of respondents say they rated the difficulty of data capture and submission either extremely or considerably difficult. Another 37% noted moderate difficulty.²

“I did quite a bit to get ready,” says Joseph Flood, MD, a member of the ACR board of directors and a rheumatologist in solo practice in Columbus, Ohio. “I worked with my billing company to make sure they understood the process and created the codes to report to CMS. I had to redesign the billing form I use and then educate staff on the changes and why they were important.”

Those using paper medical records found they had to build redundancies into their practice. Some indicators only had to be addressed yearly. However, there was often no easy way to confirm completion. This meant that physicians conforming to PQRI’s requirements had to go over indicators each time a patient was seen to ensure they were covered at least once.

Report Structure Concerns

The structure of the reports also proved to be problematic. “One indicator was whether a patient with osteoporosis had had a DEXA test recently,” says Karen Kolba, MD, a rheumatologist in solo practice in Santa Maria, Calif. “Instead of just yes or no, there were a number of modifiers. To accurately answer the question, we had to track down whether the patient had a bone density study elsewhere and confirm the results.”

Even those practices with computerized medical records found integrating the requirements of reporting with their particular program challenging. The frustration level for many practices increased after the first year of reporting ended on December 31, 2007. Payments were delayed until the second half of 2008. Many physicians not only did not get their payment, but also were unable to find out why. For others, bonus checks were far smaller than anticipated. The MGMA report found that as of August 2008, 29.6% of those responding say they did not know if their practice had earned a bonus. An additional 8.6% had been turned down.

Dr. Flood says he was in the dark on his bonus for several months. Then, a check appeared from CMS with no explanation of what it was for. It took more time to confirm the money was due to him before cashing the check.

“I did not get the bonus, and to this day, I don’t know why,” says Dr. Kolba. “Despite the best efforts of several employees, including my information technology expert, I just wasn’t able to penetrate the Web site and finally gave up.” She wasn’t alone, according to MGMA. Approximately one in four respondents (28.8%) had attempted to access the report and gave up due to difficulties. Around 70% rated accessing the feedback report as extremely or considerably difficult.

Even those able to fight through the Web site protections to get to the data were still left in the dark. “Once you got the data, it was hard to figure out your deficiencies,” says Dr. Baraf. “There was no way to go back and look at the paperwork to see if you were having problems with coding, linking a measure to a diagnosis, or other areas. Typically you get information from CMS on denied claims, but this was totally opaque.”

Proof of Concept

Some of these problems are likely related to the newness of the effort, and some to resource allocation at CMS. “At this time, PQRI is really in the proof-of-concept stage, and no one thinks that this is its final form,” says Dr. Borenstein. “CMS is stuck with generating a system to implement the law but has not necessarily been given the resources to make it successful.”

Even some rheumatologists who received bonuses were not sure they had covered the additional expenses incurred to comply with the initiative. “Our 12-person practice received about $8,000, and only three physicians qualified for payment,” says Dr. Baraf. “I doubt that covered the cost of paper and posting. We were very disappointed in the money for the amount of effort we put in.”

Dr. Flood agreed, noting that two-thirds of his bonus was used to cover compliance costs. In addition, much of the work done in one year must be repeated annually as the quality parameters and diseases covered expand. There do not appear to be many costs from last year to be amortized further this year.

CMS acknowledged many of the concerns voiced here in their Physician Quality Reporting Initiative (PQRI): 2007 Reporting Experience publication, released in December 2008. Included in the report is a listing of the major reporting errors that should provide at least a general overview of what kinds of mistakes were being routinely made. CMS also outlined some changes they hope will improve access without impairing security.

Among all the concerns, there have been some positive things to come out of the first year of PQRI. “We think we are giving quality care all the time and most of us try our best,” says Dr. Borenstein. “Some fall through the cracks, or we forget to follow up on something. PQRI served to raise our consciousness and reminded us to ask the patient questions we may have assumed had already been addressed.”

Participants Ambivalent About Continuing

The physicians interviewed were, at best, ambivalent about continuing the program. “If I wasn’t involved with ACR, I think I would be very cautious about investing staff time and effort to PQRI,” says Dr. Kolba. “If this was my first time, I would be reluctant and probably tell others to let it go through additional iterations before committing time to it. I want to make sure that others are happy with the program before going in again.”

Dr. Baraf says his group will probably stay involved. PQRI represents their only way to get enhanced revenue from Medicare. “Corrected for 2001 dollars, Medicare reimbursements are down around 24% in relative value to the dollar and Medical Consumer Price Index (for inflation),” he says. “This is the way you have to play the game if you are going to keep up with expenses.”

Kurt Ullman is a freelance writer based in Indiana.

References

1. Center for Medicare and Medicaid Services. Physician Quality Reporting Initiative (PQRI): 2007 Reporting Experience. www.cms.hhs.gov/PQRI/Downloads/PQRI2007ReportExperience.pdf. Accessed June 3, 2009.
2. Medical Group Management Association. Medical Group Management Association, Legislative and Executive Advocacy Response Network Physician Quality Reporting Initiative. www.mgma.com/WorkArea/showcontent.aspx?id=21972. Accessed June 3, 2009.