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Medicare’s new voluntary reporting program, the Physician Quality Reporting Initiative (PQRI), is the first CMS national program to link the reporting of performance data to physician payment. The PQRI will begin on July 1, 2007 and is the successor to the Physician Voluntary Reporting Program (PVRP), which began in 2006 but was not linked to payment. While the title of the program is specific to physicians, many non-physicians, including nurse practitioners, physician assistants, and nurse anesthetists, are eligible to participate in the program.
Clinicians who meet the established criteria for reporting will be eligible for a bonus payment of up to 1.5 percent of allowed charges on all Medicare claims from July 1, 2007 through December 31, 2007 that will be paid to the tax identification number. Practices interested in participating will select performance measures on which they must capture quality data for 80 percent of the procedures included in their selected measures. The bonus payment for the specified six-month period will be paid as a lump sum in mid-2008.
The PQRI is authorized by section 101 under Title I of the Tax Relief and Health Care Act of 2006, Public Law 109-432.
Reporting Performance Measures
The PQRI will use administrative data sets to capture clinical data needed to evaluate performance. The performance measure data will be reported on the same claim form as the procedure code(s), generally using Current Procedural Terminology (CPT) Category II codes. To report quality data for 2007, the PQRI does not require participation in a registry or a Medicare participation agreement. Clinicians can simply start reporting on July 1, 2007 on either the same claim form (CMS 1500) or the same electronic transaction (ASC X12N 837). Each clinician must determine which quality measures he/she can report based on the relevance of the measures to the clinicians’s practice. If up to three performance measures are relevant, the clinician must meet an 80 percent reporting rate for all measures. If four or more measures are selected, at least three measures must meet the 80 percent reporting threshold to qualify the clinician for the full bonus payment.
PQRI Performance Measures
For 2007, there are 74 performance measures that clinicians can select from for reporting to the PQRI. The included measures were developed by physicians for physicians, including many through collaboration with the AMA’s Physician Consortium for Performance Improvement. In addition, the performance measures have been vetted through the AQA (formerly the Ambulatory Care Quality Alliance) and/or the National Quality Forum (NQF).
Payment
Clinicians who qualify will receive a bonus payment of up to 1.5 percent of the allowed charges for all services performed under the Medicare Physician Fee Schedule in the last six months of 2007. Quality codes will be routed through the CMS payment system, analyzed, and considered in bonus eligibility calculations. A single bonus payment will be paid in mid-2008 to the holder of the taxpayer identification number.
A cap on the payment has been created to limit the bonus for physicians who report relatively little quality data. The cap is calculated as follows.
Payment Cap = (I)[300 percent (A/M)], where I= # of measures an individual reports; A= national allowanced charges associated with measures; and, M= national instances of measures reported.
Results of Reporting
Physicians who participate in the reporting of performance data will receive a single confidential quality report around the time of the release of the bonus payment. Details regarding the report have not been finalized, but the summary will contain the data necessary to compute the bonus payment. The goal of the 2007 PQRI is to provide physicians with experience reporting quality data and for the calculation of bonus payments, and therefore, the information will not be released to the public. In addition, CMS is developing an inquiry process that would permit the correction of any obvious errors and an audit system to verify the accuracy of quality data submitted.
Future Steps
With the change in Congressional leadership and the growing desire by healthcare stakeholders to promote physician accountability for the quality of care they provide, the future of this program is unclear. The College is taking an active role in examining and influencing the future of the PQRI by recruiting a wide variety of practices to track their experiences with the PQRI. The information gathered during this project will be reported to CMS and Congress.
In addition, the legislation authorizing the PQRI references the use of registries in data collection for 2008. The ACS’s Case Log System, along with the ACS National Surgical Quality Improvement Program, is being examined for potential use in the PQRI for future years.
Online May 15, 2007
PQRI
