ACS Bulletin Article
January 2008 Preview
Socioeconomic Tips: Medicare pay-for-reporting program to continue in 2008
by Julie Lewis, Quality Affairs Consultant
The Centers for Medicare & Medicaid Services (CMS) will continue the voluntary pay-for-reporting program, known as the Physician Quality Reporting Initiative (PQRI) in 2008. The PQRI is the first nationally available program for the reporting of individual provider-level performance data. Authorized by the Tax Relief and Health Care Act of 2006 (TRHCA), the first PQRI reporting period launched in July 2007 and concluded on December 31. The 2008 reporting period, which will serve as an opportunity for new participants to begin reporting, will run from January 1 through December 31.
Performance measures available for reporting
For 2007, 74 performance measures were available for reporting by physicians and other health care professionals. Specialty societies, often in collaboration with the American Medical Association’s (AMA) Physician Consortium for Performance Improvement (PCPI), developed many of the performance measures included in the program.
To increase consistency among the performance measures, TRHCA mandated that all measures included in the 2008 program be endorsed by the National Quality Forum (NQF) or approved by the AQA (formerly the Ambulatory Care Quality Alliance). The NQF and AQA are multi-stakeholder organizations that promote consensus-based endorsement or approval of performance measures.
The performance measures for the 2008 PQRI include the following:
- 59 measures from the 2007 PQRI measure set
- 38 new measures from the AMA PCPI
- Seven non-physician measures developed by Quality Insights of Pennsylvania, a CMS Quality Improvement Organization (QIO)
- Two structural measures developed by Quality Insights of Pennsylvania
- Five additional measures from the AQA Starter Set, a measure set approved by the AQA for measurement of primary care physicians
- Six measures developed by the American Podiatric Medical Association.
In 2007, CMS received numerous comments regarding the inability of some physicians and other health care professionals to participate in the PQRI due to the limited measure set. The contract with the Pennsylvania QIO to develop specific performance measures was one method CMS used to broaden the program. The structural measures developed by the QIO are in accordance with TRHCA and include the adoption of e-prescribing and the use of electronic medical records.
The American College of Surgeons developed a set of surgical performance measures in 2006, known as the Perioperative Care Measure Set, in collaboration with the AMA PCPI and the Surgical Quality Alliance. The measure set comprises six measures related to antibiotic and venous thromboembolism prophylaxis which were endorsed by the NQF, approved by the AQA, and included in the 2007 and 2008 PQRIs. Other measure topics in the 2008 PQRI that could be of interest to surgeons include stroke, osteoporosis, eye care, coronary artery bypass graft, urinary incontinence, acute otitis externa, and otitis media with effusion.
Choosing measures to report
At press time, CMS had posted the first version of measure specifications on their Web site at www.cms.hhs.gov/PQRI. While no additional measures can be added, minor changes and corrections can continue until the end of 2007. Surgeons interested in participating should choose three performance measures to report and may want to consider the following factors:
- A minimum of three measures should be chosen, assuming that at least three apply to the surgeon’s practice
- If fewer than three measures from the measure list apply to the practice, then only the relevant one or two measures should be reported.
- If three measures only cover a small portion of Medicare patients in the practice, then additional measures should be chosen.
Payment cap
As a general rule, PQRI participants should choose performance measures that will allow them to report quality data for most Medicare patients in their practices. Using this approach will prevent the provider from getting caught in the PQRI payment cap, which is invoked based on the volume of quality reporting. The cap, which is present in both the 2007 and 2008 programs, was designed to penalize participants who report a relatively small amount of quality information.
Bonus payments
Participants who report quality data for at least 80 percent of appropriate Medicare claims are eligible for a bonus payment. For 2007, participants could receive a bonus payment of up to 1.5 percent of all Medicare claims allowed during the reporting period. At press time, a specific percentage had not yet been set for 2008 because of legislative language in TRHCA that includes a $1.35 billion aggregate limit on bonus payments. CMS has stated that the 2008 bonus payment per provider will likely be 1.5 percent of all Medicare claims.
Unfortunately, data regarding 2007 bonus payments were unavailable at press time and by the launch of the 2008 PQRI. CMS has stated that provider reports and bonus payments for the 2007 program will not be distributed until mid-2008. In the 2008 program, participant feedback reports will continue to include all PQRI data used to calculate the eligibility and amount of the bonus payment. CMS will be unable to provide interim reports for 2008 until after the 2007 feedback reports have been distributed. Because an 80 percent reporting rate is needed to qualify for the full bonus payment, participants should begin reporting immediately in January.
Reporting of quality data
As in the 2007 program, CMS has stated that provider-level data collected in the PQRI will not be publicly reported. Whereas aggregate data might be available, information that could allow for physician or group identification will not be posted.
Data collection and submission
For 2008, performance measures will continue to be collected using Current Procedural Terminology Category II codes or G-codes using the Medicare claims processing system. These codes should be submitted on the same claim as the related procedure or visit. Additional information regarding quality data submission is available on the ACS and CMS Web sites.
In compliance with TRHCA, CMS will test data submission from alternative sources such as registries and electronic health records (EHR). Two methods of data collection by registries will be tested by voluntary, self-selected registries. Under the first method, the registry will collect the relevant quality data, as well as diagnostic and procedure codes. CMS will use beneficiary information to match the quality data to the information in the related claim and calculate provider performance rates. Under the second method, the registry will collect all data necessary to calculate reporting and performance rates. A validation process is required for the second option. CMS will also partner with self-nominated EHR vendors to test clinical quality data submission. It is important to note that providers participating in registry and EHR testing also need to submit quality data via the claims processing system to be eligible for the bonus payment in 2008.
College activities
For the 2007 program, the College developed guides and tools to assist surgeons who were interested in participating; these materials are available at www.facs.org/ahp/pqri. The Web site, which will be updated for 2008, includes an introductory presentation, workflow sheets to assist surgeons’ offices in measure collection, a sample claim form, measure specifications, and answers to frequently asked questions.
In addition, the College has developed a program to examine the implementation and burden of reporting to the PQRI program. Twenty surgical practices have volunteered to participate in the ACS PQRI monitoring program. Using information from these practices, the College has identified implementation challenges in the program and communicated them to CMS. The College will continue to follow these practices through the end of the reporting period as well as track CMS provider feedback and bonus payment.
Online December 6, 2007
PQRI
