In 2007, the Centers for Medicare and Medicaid Services (CMS) established the Physician Quality Reporting Initiative (PQRI), which later morphed into the now ubiquitously referenced Physician Quality Reporting System (PQRS). Starting Jan. 1 this year, physicians who did not participate in the pay-for-reporting system stood to lose 1.5% of allowable Medicare charges.
Explore This IssueFebruary 2015
For otolaryngology, the issue was even more dire than a practice losing a portion of its already strained revenue stream. The CMS system afforded the specialty no measures groups, the billing term for an aggregated list of individual measures that relate to the field. Instead, otolaryngologists could only choose to file for individual measures, whose reporting guidelines are more involved, time-consuming, and costly than measures groups.
But that grim situation is no more.
The American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) and the American Board of Otolaryngology (ABOto) came together early last year to create two new measures groups for otolaryngologists that were ultimately approved for use by CMS. The groups will cover acute otitis externa (AOE) and adult sinusitis.
“We’re a very heterogeneous specialty,” said Randal Weber, MD, chair of head and neck surgery at The University of Texas at MD Anderson Cancer Center in Houston and the ABOto president-elect. “Some of us see primarily head and neck cancer, while others see patients with ear problems. Some are in academic practice, and others are in solo or multi-specialty private practice arrangements. “So having a measure group may particularly benefit the private practice otolaryngologist, because it covers a spectrum of patients that they would normally see in their practice and opens up [PQRS participation] to a lot of practitioners in otolaryngology,” he added.
AAO-HNSF and other specialty associations began discussing proposed measures groups early in 2014, with the goal of presenting them to CMS for approval. Last summer, negotiations continued, and by the November release of the Medicare Physician Fee Schedule Final Rule, CMS approved the measures groups for inclusion in PQRS in 2015.
“It’s difficult to measure quality improvement without measures,” said James C. Denneny III, MD, the new executive vice president and chief executive officer of the AAO-HNS and its foundation. “Putting together parameters is very difficult, because it involves reviewing literature, hundreds of articles, by panels that are versed in doing this, and then selecting what has the evidence to support proven ways to do this, and a lot of that evidence does come from these types of clinical studies. So [this is] a transition step to where we’re going now, where we’ll have precise parameters that are measurable across the country to guide consistency in treatment for patients across the board.”
Why Measures Groups?
Given the fact that otolaryngologists already have the ability to report on individual measures, some practitioners might wonder why measures groups matter at all. Dr. Denneny said there are several reasons.
First, he estimates the percentage of otolaryngologists who participate in PQRS at roughly 35%. With the broader availability of measures groups, he believes that could rise to “well above 50%.” That is because measures groups require less overall reporting.
To wit, eligible physicians who use the PQRS “individual measure” option must report on 80% of their eligible Medicare Part B fee-for-service patients for that coding number. But physicians reporting for a measures group, often via
PQRSwizard, need only report on 20 patients for the group. “Having to only report on 20 patients for each group is considerably easier than picking a percentage of all the patients with that diagnosis,”
Dr. Denneny said. “It’s much more doable even in the era of electronic health records.”
A second reason a measures group is important, he added, is that it will further improve care delivery. “We were hoping that at the end of the day, measures like this will end up populating future registries that would subsequently report results which are standardized and, overall, continue to improve quality of care,” Dr. Denneny said.
To be clear, while the measures groups are in place starting this year, the reporting period is on a lag. The 2015 calendar year, which is subject to the 1.5% deduction, is based on the 2013 reporting period. In 2016, the payment reduction rises to 2%, based on 2014 data.
Dr. Denneny said the new measures groups will likely provide a reporting option for 70% to 75% of otolaryngologists. Still, laryngologists, for example, or head-and-neck surgeons might not see 20 patients with AOE or sinusitis. That means their only reporting option remains individual measures. Crafting additional measures groups that might help subspecialty otolaryngologists might seem like a good idea, but doing so before the efficacy of the first two groups can be analyzed would be premature, Dr. Weber said.
“We need to see how well this first measure group is accepted,” he added. “It does need to be as broad as possible, but I also think from this first measure group we will get insight into the mechanics, how easy is it to participate, and how easy is it to collect the data and report it.”
Another value of the measures groups for otolaryngologists could be to fulfill Part IV of the American Board of Medical Specialties” Maintenance of Certification (MOC), which focuses on using data from a practice to improve outcomes. In particular, required components of ABOto’s Part IV include patient surveys on their experience with the diplomat, a professional survey, and completion of a practice improvement module.
“There are a lot of different ways to fulfill Part IV, and our board has taken the approach that if we can add value to Part IV by fulfilling PQRS and fulfilling the MOC requirement at the same time, that’s really win-win,” Dr. Weber said. “I think we’re going to learn a lot from this initial measure group, and if it’s widely endorsed by the appropriate group of otolaryngologists who see patients with these clinical problems, then it would be easier to incorporate it into Part IV of MOC.”
After the new groups can be properly evaluated, it will be time to build more measures groups, Dr. Denneny said. In fact, the AAO-HNSF is already working on a “prioritized list” to be ahead of that process. “We’re looking at doing something with thyroid disease for the head and neck surgeons, which we could combine with multiple specialties like general surgery and some of the others,” he said. “We have a prioritized list, which hoarseness is on. So what we have to do with our limited resources is put the most common forth, but there is a list that we’re working on and will continue to work on as we go forward, so we’re not stopping with these two.”
One complicating factor is that otolaryngology isn’t the only specialty pushing for additional measures groups. Other groups are rightfully pushing for rules beneficial to their specialties. But, as Dr. Denneny said, the continued efforts by the AAO-HNSF and others show that progress is being made.
“This is a step in the right direction,” Dr. Denneny added. “Physicians have the ethical responsibility and the ethical desire to do the best they can for their patients, just like our academy and the other medical associations do…. This allows them comfort in knowing that this is what their colleagues do, that this has been vetted by experts in the field, and this is the best way to do it.”
Richard Quinn is a freelance writer in New Jersey.