Physician Quality Reporting Initiative, 2007: A “mid-term” perspective

CMS reviews its program to date and comments on likely developments for 2008

Thomas B. Valuck, MD, JD

Director, Special Program Office for Value-Based Purchasing,
Centers for Medicare & Medicaid Services Baltimore, MD

Key Points

CPT Category II codes allow the capture of PQRI quality data through claims-based reporting
Additional PQRI measures for 2008 will include those endorsed by the National Quality Forum or adopted by the AQA Alliance by November 2007
Registry-based reporting for PQRI will likely be tested during 2008

In July 1, 2007, CMS launched the Physician Quality Reporting Initiative (PQRI), an important first step toward its new commitment to “value-based purchasing.” The PQRI was established to reward the high-quality health care that professionals strive to provide every day. The aims of this measure reporting process include improving clinical quality, reducing adverse events and ensuring patient safety, encouraging patient-centered care, avoiding unnecessary costs in delivering care, stimulating investments in effective electronic health systems, and making performance results transparent and comprehensible.

FAST TRACK

Updated information on PQRI measures and reporting tools can be found at the CMS Web site

Created by the Tax Relief and Health Care Act (TRHCA) in December 2006, PQRI supports physicians in several ways. It enhances professionalism through accountability, provides feedback for performance improvement, encourages investment in the future of the practice, and, for those who successfully report on a set of specific PQRI measures between July 1 and December 31, 2007, pays a bonus of up to 1.5% of the total allowed charges for Medicare physician fee schedule services.

Value-based purchasing, sometimes referred to as “pay-for-performance,” is the future of Medicare reimbursement for all of our payment systems. Commercial carriers, too, are adopting similar pay-for-performance programs.

Participation in PQRI will help make performance reporting a routine part of patient care for physicians and their staff.

Details of the program

PQRI is a voluntary program. Physicians, therapists, and several other types of clinicians can participate. No registration is required. Participants must be enrolled in Medicare, but they do not need to be Medicare participating providers who accept assignment to submit PQRI quality data.

PQRI incorporates consensus-based quality measures developed by physician groups like the AMA’s Physician Consortium for Performance Improvement (PCPI) and adopted and endorsed for use by groups like the AQA Alliance and the National Quality Forum (NQF).

Seventy-four measures were available for reporting when the PQRI launched on July 1. More than one third of these are relevant to primary care practice. Participants choose up to 3 measures to report. Additional measures will be added for 2008 through the Medicare Physician Fee Schedule rulemaking process.

The genesis of value-driven health care, value-based purchasing, and PQRI

In August 2006, the President issued an Executive Order on health care quality and transparency. it laid out 4 cornerstones basic to quality health care: transparent quality information; transparent price information; interoperable health information technology; and incentives for health care delivery driven by value to the patient, not volume of services.

These cornerstones of value-driven health care are reflected in the center for Medicare & Medicaid Services’ (CMS) value-based purchasing initiatives, which include PQRI. the use of incentives to improve health care value is a seismic shift for Medicare, from passively paying for health care services to actively purchasing high-quality, efficient care. these are long overdue changes that CMS is working hard to achieve.

When Medicare was launched in 1965, claims were paid based on customary, reasonable, and necessary costs. as health care costs began to rise sharply in the 1980s, Medicare moved to a prospective payment system for hospitals, but Medicare fee-for-service payment for ambulatory services continued to be based on resource consumption and quantity of care.

As a result, Medicare payments don’t support health professionals’ efforts to provide the best care to their patients; they don’t help patients seek health care that will help them stay well and manage chronic illness. instead, the rules of the Medicare payment system too often reward unnecessary treatment, duplicative services, and care that addresses the complications of disease but fails to prevent them.

With PQRI, we aim to turn these disincentives around.

Over the past few years, Medicare has made considerable progress toward value-based purchasing, founded on measurement of performance using evidence-based measures of quality developed by physicians for physicians.

This would not have happened without consensus. CMS has been working with a broad array of stakeholders—health professionals, institutional providers, purchasers, payers, consumers, and others—who are developing measures of heath care quality. CMS is also working with these stakeholders to develop useful and fair measures of health professional resource use.

Selecting measures to report

Updated information about evolving PQRI measures, as well as detailed measure specifications and reporting tools, can be found on the Center for Medicare & Medicaid Services (CMS) Web site at http://www.cms.hhs.gov/PQRI. Just go to the site, click on the Measures/Codes link, and select the desired downloads. Participants are encouraged to choose measures that most closely relate to the types of care they provide to Medicare patients, as well as the settings in which they work. Specifications for the chosen measures can then be printed to guide successful reporting of that measure.

Consider diabetes, for example. Measures related to HbA1c, cholesterol, and blood pressure apply to diabetes patients. For physicians who provide diabetes care, these 3 measures could comprise the requisite minimum number for reporting. The ICD-9 code for diabetes defines the denominator for these measures and identifies the opportunity for reporting. The CPT Category II codes that are reported according to each measure’s specifications make up the numerator.

Collecting the data

The PQRI Web site offers several tools, including data collection worksheets, that help identify patients to whom the selected measures apply, translate the quality data into the administrative claim process, integrate the measures into the practice routine, and enable analysis of your own data.

Submitting data

A simple, but necessarily precise, method for claims-based reporting is detailed on the PQRI Web site. PQRI quality data codes allow reporting of 3 distinct circumstances: the measure requirement was met; the requirement was not met due to documented, allowable exclusions; or it was not met and a reason is not documented in the medical record. For example, with a patient who has coronary artery disease, any of the following PQRI scenarios would represent acceptable reporting for an office visit: the patient is receiving oral antiplatelet therapy (CPT-II code 4011F); antiplatelet therapy is contraindicated due to a concomitant bleeding disorder (4011F-1P modifier); or there is no documentation that the physician addressed appropriate therapy (4011F-8P modifier).

Note that you must correctly use your new National Provider Identifier (NPI) as part of reporting.

Feedback reports

Feedback reports—which should include reporting and performance rates—will be confidential in the first year of PQRI. CMS will not report 2007 quality data to the public at the individual or practice level. At or near the time of the bonus payments in mid-2008, CMS will make reports available to participating clinicians who request them.

Performance-based payment incentives work

To test the application of value-based purchasing to physician practice, CMS has been conducting onsite demonstrations over the past few years. For instance, early results are encouraging from 2 large group practices participating in the CMS Physician Group Practice Demonstration. For management of heart failure, one clinic prevented 160 unnecessary hospital admissions over 8 months, saving approximately $1 million. Another clinic prevented more than 40 readmissions per month. For diabetes control, one clinic increased dilated eye exams by 20% over 2 years and increased well-controlled cholesterol levels by 33%. Another clinic increased results of 5 diabetes measures by 79%.

Expectations for 2008

FAST TRACK

CMS proposes to test registry-based reporting during 2008

A final decision on rules and processes for 2008 will not be available until the Medicare Physician Fee Schedule (MPFS) 2008 Final Rule is released, probably in November. Nevertheless, considerable insight was provided in the MPFS 2008 Proposed Rule.

Financial incentive

CMS proposed to use the $1.35 billion Congress allocated under the Physician Assistance and Quality Initiative fund for quality bonuses to reward successful reporting during 2008.

Clinical measures

CMS is proposing that some of the 74 measures used in 2007 that failed to achieve NQF endorsement be dropped. New measures have been proposed for the list if they are endorsed by NQF or adopted by AQA Alliance by November 15 (as directed by the TRHCA). Additional measures could include those developed by the PCPI or Quality Insights of Pennsylvania, remaining measures from the AQA Starter Set not activated in 2007, or other NQF-endorsed measures. TRHCA further specifies that the 2008 PQRI measures must include 2 or more measures submitted by a physician specialty and 2 or more structural measures, such as the use of electronic health records (EHRs) or electronic prescribing.

Registry-based data submission

CMS proposes to test the use of registry-based reporting during 2008. In the Proposed Rule, CMS discussed several options for collecting PQRI quality data from clinical registries.

We want to work with you

The more we can support health professionals and patients in pursuing the highest care at the lowest cost, the less pressure there will be on professional payment rates and Medicare solvency and, most importantly, the better the quality of care will be for Medicare beneficiaries. Done right, everyone wins—patients as well as the providers who care for them.