Medical Economics Feature - October 2008
Tex Med . 2008;104(10):35-38.
By Ken Ortolon
When the U.S. Centers for Medicare & Medicaid Services (CMS) launched its pay-for-performance reporting project in 2007, Greenville family physician Peter Gray, MD, decided to participate because he believed such quality reporting eventually would be mandatory and not just for Medicare.
"The main reason I did it is because I think this is something that all insurance companies are going to ask for," Dr. Gray said. "I thought this would give us a leg up in starting the process of learning how to do that reporting."
In July, Dr. Gray was one of 56,700 physicians and other health professionals around the country who received more than $36 million in bonus payments for reporting quality data under the Physician Quality Reporting Initiative (PQRI).
While CMS officials still are analyzing the data, they hope ultimately to be able to "make inferences about the quality of care" being provided to Medicare beneficiaries. CMS also is providing feedback reports to participating physicians that it hopes will help them improve their performance on quality measures.
Although Dr. Gray believes PQRI has helped improve his care of patients with diabetes, congestive heart failure, and osteoporosis, Texas Medical Association officials doubt its overall value and the direction CMS officials likely will take it.
TMA President Josie R. Williams, MD, says CMS eventually will want to use quality reporting to measure outcomes and accountability. At this stage of the game, that's putting the cart before the horse, she says.
"It's not fair to begin using accountability measures to pay physicians or penalize physicians before we're really sure how good those measures are," said Dr. Williams, who also serves on the executive committee of the Physician Consortium for Performance Improvement. "The political agenda for getting information about the care delivered is far, far, far ahead of the science of measurement of that information. The real concern is not the measurement but the implementation of the measurement to be used for accountability."
In mid-July, CMS announced bonus payments to health professionals who had satisfactorily reported PQRI information to Medicare during 2007. CMS asked physicians to voluntarily report on 74 different quality measures involving bronchitis, heart disease, asthma, diabetes, congestive heart failure, osteoporosis, preventive care and screenings, and other conditions.
Physicians who qualified received a bonus payment equal to 1.5 percent of all of their approved Medicare charges for the reporting period. CMS says payments to solo practitioners averaged about $600, while physician groups received approximately $4,700.
Dr. Gray, who supervises three mid-level practitioners in his practice, says his bonus was roughly $4,600.
CMS spokesperson Allison Henry says 413 Texas physicians or practices qualified for bonus payments for 2007 and received $1.95 million.
In announcing the bonus payments, U.S. Health and Human Services Secretary Michael Leavitt said a value-based purchasing system is a critical way to improve the health care system. "By collecting quality data, health care providers can use the information to improve the quality of care to beneficiaries," Secretary Leavitt said.
"These payments to physicians for participating in the PQRI are a first step toward improving how Medicare pays for health care services," added CMS Acting Administrator Kerry Weems. "We all can agree that the current payment system needs to be reformed to pay for high-quality care rather than continuing to pay for the volume of services. The PQRI has proven to be a successful step towards establishing a value-based purchasing program for physicians."
Dr. Gray says reporting the quality data was relatively easy for him because he uses an electronic medical record (EMR) system in his practice. He chose to report on three conditions during the first year: diabetes, congestive heart failure, and osteoporosis. Because his EMR has a quality template that pops up automatically, it was a simple matter of checking the appropriate box to indicate that he had checked a patient's hemoglobin A1c level, LDL cholesterol level, or bone density.
"All that data goes right on the MOB [medical office bill] we send off to Medicare," Dr. Gray said. "If you don't have an EMR, you would have to do all that by hand," which he says would be very time consuming.
Ms. Henry says PQRI is "still a new and evolving structure," so conclusions are still being formed. For 2008, CMS increased the number of quality measures from 74 to 119. Bonus payments also will go up to 2 percent in 2009.
While CMS is still fine-tuning its data analysis, it already is giving physicians feedback reports that Ms. Henry says they can use to gauge their performance on professionally recognized standards of care and take steps to improve their performance. (See " Feedback Reports Available for 2007 PQRI Participants .")
The reports will tell practitioners how many times they reported a particular measure and how their care compares with professionally recognized standards of care, she says. They also include incentive information that tells a physician how much of a PQRI-related bonus he or she received, based on his or her reporting rate and the amount of applicable claims for the reporting period.
TMA officials say, however, that some physicians cannot yet access their feedback reports because of a glitch in CMS's enrollment system. In 2003, TrailBlazer Health Enterprises and other Medicare carriers converted to a new enrollment system called the Provider Enrollment, Chain and Ownership System (PECOS).
Teresa Devine, director of TMA's Payment Advocacy Department, says TrailBlazer has not transferred data from the previous enrollment system to PECOS. Therefore, physicians who have not reenrolled in Medicare because of a change of address or other reason since PECOS was adopted will not be able to access their PQRI feedback reports.
Ms. Henry says physicians who have not submitted a Medicare enrollment application since November 2003 will need to do so if they want to get their feedback reports. More information about the enrollment process is online .
Dr. Gray says he has not yet seen his feedback reports, but he can generate quality reports related to his PQRI reporting from his own EMR system. He believes participating in PQRI enabled him to improve the care he gives his patients.
"We kind of intuitively had the idea that we were doing a great job," he said. "Then you look at the numbers and find you're not doing as well as you thought you were."
Dr. Gray says his analysis of his own data showed that his patients with diabetes were not always getting an annual retinal examination, which required them to see an ophthalmologist or optometrist. In response, Dr. Gray purchased a camera so he can take retinal photographs while the patients are at his clinic. Now, he said, "it doesn't matter whether they go to the ophthalmologist or not, we've got that in our system."
He also is paying closer attention to patients' blood pressure because of his quality reporting.
Dr. Gray says he will continue in PQRI and likely will expand his reporting to cover heart disease and stroke.
Dr. Williams recommends that all physicians begin looking at ways to measure their performance, whether or not they participate in PQRI. She says data clearly show that when physicians measure, they show improvement in the care they deliver. "More patients get the appropriate vaccines, more patients get better screening for their diabetes, and doctors are more aware of the patients who have hypertension that should be controlled," she said.
Knowing the Limitations
Dr. Williams still has concerns about PQRI because CMS relies on claims data, not the medical record. Claims data simply can't reflect instances, for example, where it might be inappropriate to follow a quality measure for a particular patient, such as giving antibiotics within four hours of hospitalization to someone suspected of having community-acquired pneumonia. As often as not, it turns out the patient actually has bronchitis, congestive heart failure, or another disease, she says.
"The measure is written around the literature, but there's no way to prevent people from trying to react by rote to what they see as the measure rather than understand the measure, implement the measure appropriately, and make appropriate exclusionary remarks in their records to keep from getting dinged," Dr. Williams said.
She also says that while the scientific literature shows measurement leads to performance improvement, it has not yet shown that such improvement can be tied to improvement in outcomes.
"The Physician Consortium has begun to try to develop measures across disease-specific entities that we know are good medicine," Dr. Williams said. "They may or may not necessarily lead to [better] outcomes because you don't know that. It takes 10 to 15 years to look at outcome data."
CMS already has indicated that its goal is to reward physicians who meet quality measures and penalize those who don't, but Dr. Williams says basing accountability on performance measures is not ready for prime time.
"Accountability measures have to be hard science, hard showing of value, and you have to absolutely be able to count it appropriately to know what the exclusions should be and to be able to make sense out of that when you give a report back to an individual physician." The science simply isn't there yet, she says.
While measurement for improvement is "most productive for physicians," basing payments on such measurement at this time is not, Dr. Williams added.
"I used to think that would be one of the ways we could get a few more dollars and do the right thing. But the way it's being rolled out makes me very anxious."
The U.S. Centers for Medicare & Medicaid Services (CMS) says 2007 Physician Quality Reporting Initiative (PQRI) final feedback reports are available on a secure Web site. The reports are organized by tax identification number.
Two MLN Matters articles on accessing the reports can help individual physicians and group practices get access to the information. Links to both are available on the TMA Web site at www.texmed.org35464.html :
Once you are registered and have access to the PQRI feedback reports, direct any questions about the reports to the Report Delivery System Help Desk referenced at the end of the articles. Additional educational resources and information about the PQRI program are available at www.cms.hhs.gov/PQRI .
Some physicians may not be able to access their feedback reports if they have not enrolled or reenrolled as a Medicare participating physicians since November 2003, when CMS implemented a new tracking system.
CMS spokesperson Allison Henry says physicians who have not submitted a Medicare enrollment application since November 2003 will need to do so if they want to get their feedback reports. More information about the enrollment process is at www.cms.hhs.gov/MedicareProviderSupEnroll .
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon .