Reimbursement and Outcome Measurement in Otolaryngology Practices: What the Government Can Do to You and for You

WASHINGTON, DC-Contrary to popular belief, CMS is in the business of paying for quality care, not just the volume of care provided. We’ve been doing this for about 10 years now, David Hunt, MD, Medical Officer in the Office of Clinical Standards and Quality of the Centers for Medicare and Medicaid Services (CMS)-and a practicing surgeon -said in a miniseminar at the recent annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery.

CMS is no longer the big bad wolf of payment denial; it is now based on the principle that health care dollars are well spent if quality is high. Outcome measures are important, of course, but they are not the true picture of quality, said Dr. Hunt. He did not define what that picture actually is-perhaps because there are no such specific standards-but he did say that evidence-based practice grounded in randomized clinical trials and cohort or ecological studies is the agency’s goal.

CMS Speaks

Otolaryngology patients (as well as their physicians) are getting older, which is why Medicare plays such an important role in their lives. One of the programs, the Medicare Quality Monitoring System (MQMS), is part of the effort to monitor and improve the quality of care delivered to Medicare beneficiaries.

The features of MQMS include quality indicators of health care, utilization and outcome quality measures, administrative data, trends in the provision of health care, various clinical and topical areas, national and state-level outcomes (not hospital outcomes), and adjustments to standardized distribution based on age and sex.

MQMS also looks at beneficiary characteristics, and utilization describes their demographic distribution and rates of hospitalization for the most common diagnoses and procedures (many of which are otolaryngologic). Data are collected and tabulated for each diagnosis and procedure at the national level and by gender, age, race/ethnicity, Medicaid enrollment status, urban/rural location, and census region.

The Physician Quality Reporting Initiative (PQRI), another fairly recent program, was wildly unpopular when it was first instituted, authorized by the Tax Relief and Health Care Act of 2006.

PQRI establishes a financial incentive for eligible professionals to participate in a voluntary reporting program. Those who successfully report a designated set of quality measures on claims (which involves a mountain of paperwork) can earn a bonus payment, subject to a cap, of 1.5% of total allowed charges for covered Medicare physician fee schedule services.

One of the things that bothered physicians was that CMS posted a letter on its Web site to Medicare beneficiaries with information about PQRI, explaining what the program is and what the implications are for patients. Physicians can choose to provide a copy to their patients in support of their participation in PQRI, but they are not obligated to do so. Neither are they obligated to participate in PQRI, which is not as roundly hated as it used to be.

The VA Model

The VA now scores better than almost all other national health care institutions because Ken Kizer initiated a significant amount of institutional change.
-David Eibling, MD

David Eibling, MD, Professor in the Department of Otolaryngology Head and Neck Surgery at University of Pittsburgh Medical Center, noted that there are few evidence-based quality measures in otolaryngology, but he encouraged the audience to use those that do exist.