The new health system reform law includes a number of quality provisions that physician organizations say are not ready for primetime and won’t be ready in the time frame established by Congress.
The two sections of most concern to medical associations involve the Physician Quality Reporting Initiative (PQRI) and the creation of a value-based payment modifier under the Medicare physician fee schedule.
The Patient Protection and Affordable Care Act not only extends PQRI through 2014, but, starting in 2015, it also institutes payment penalties for physicians who don’t report quality measures. The incentive payment for participating in the program drops from 2 percent this year to 1 percent in 2011 and 0.5 percent from 2012 to 2014. The penalty will be 1.5 percent in 2015 and 2 percent in subsequent years.
Physician groups argue that PQRI, now in its fourth reporting year, still has problems and shouldn’t become punitive until it is run properly.
“The doctors who participated in this, to my knowledge, have a difficult time getting their payments,” said Gerald Healy, MD, FACS, professor of otology and laryngology at Harvard Medical School and a former president of the American College of Surgeons. “The credibility of the program is under serious question among otolaryngologists because of prior poor experience.”
—Gerald Healy, MD, FACS
Robert Bennett, government affairs representative for the Medical Group Management Association (MGMA), said the MGMA recently discovered that the Centers for Medicare & Medicaid Services (CMS) found that analytical errors were made in determining which physicians successfully reported measures in 2008.
CMS is now making additional payments to some practices, he said. “The frustrating thing is that Congress has passed a law that makes the program punitive in 2015, and you have a situation where the Medicare agency is still trying to properly implement the second year of reporting,” Bennett said. “We have grave concerns that this program is just not ready for any sort of penalty.”
According to an MGMA survey published in January, nearly 50 percent of physicians found it difficult or very difficult to capture and submit PQRI data last year, compared with 31 percent who found it easy or very easy. When asked if the two percent payment provides enough incentive to begin or continue PQRI participation, respondents were almost evenly split, with 45 percent saying ‘yes’ and 42 percent responding ‘no.’
Specialty-Specific Measures Needed
Another problem with making PQRI punitive is the lack of quality measures to report for some specialties. Physicians in specialties that don’t have many measures or have difficulty getting measures could get hit once the payment reduction kicks in, said Kristen Hedstrom, assistant director of legislative affairs for the American College of Surgeons.
Only a small percentage of otolaryngologists participate in PQRI because few measures apply to them, said Jean Brereton, senior director of research, quality improvement and health policy at the American Academy of Otolaryngology-Head and Neck Surgery. Creating measures and getting them endorsed is a time-consuming and resource-intensive process that is especially difficult for small specialties, she said, adding that it’s not likely that the government will produce and endorse enough measures for otolaryngologists by 2015. “We are supportive of moves to be able to report on quality,” Brereton said. “It’s just the aggressiveness of the time frame they’ve laid out that we’re concerned about.”
The legislation, however, does include an alternate pathway to meet the PQRI standards, through participation in an “enhanced” Part IV of the American Board of Otolaryngology’s Maintenance of Certification Program. MOC participants will be required to complete a Part IV activity relating to performance in practice every five years in the ten-year MOC cycle. The requirement for an enhanced Part IV means that the participant must perform a Part IV activity every two years. “We are working diligently to finalize our Part IV program in the next year or two,” said Robert Miller, MD, MBA, executive director of the American Board of Otolaryngology and editor of ENT Today. “Clearly, this option will be advantageous to MOC participants.”
Ironing Out the Details
The act, signed into law on March 23, makes some improvements to PQRI, Bennett noted; the details, however, are unclear. The law requires that Medicare establish an informal appeals process for physicians who believe they should have gotten a PQRI bonus. Currently, physicians have no recourse when they disagree with CMS’ determination that they did not successfully report quality measures.
The MGMA is pressing for quarterly, if not monthly, feedback reports to physicians. Physicians participating in the 2010 PQRI, for example, haven’t received feedback on whether they successfully reported measures in 2009, so they could be unknowingly making the same reporting mistakes, Bennett said.
Physician groups also find the law’s creation of a value-based payment modifier under the physician fee schedule troubling. The modifier will provide for a differential payment to physicians or groups of physicians based on the quality of care compared to its cost during a performance period, Bennett explained. Cost is measured by resources used. “The overall goal is to provide a financial incentive to doctors to report on quality measures and to not overutilize,” he said.
According to Bennett and Hedstrom, the fundamental building blocks of the initiative haven’t been developed yet, and the time frame is too tight. CMS, for example, is still working on how to group care for a patient into an episode in order to measure resource use within that episode, Hedstrom said. The agency will also have to determine which physician the resource use is attributable to, Bennett said. For example, if a doctor asks another physician for a patient consultation, who is the consultation attributed to—the doctor who ordered it or the one who performed it?
CMS has experimented with measuring and comparing doctors’ use of resources in the Physician Resource Use Measurement and Reporting Program, but the pilot project isn’t finished yet. In the first phase, completed last year, CMS, with Mathematica Policy Research Inc., began developing and testing measures and confidential feedback reports that compare physicians on their relative resource use. About 310 reports were sent to randomly selected physicians. The second phase, which is in development, is expected to run through 2011.
This value-based modifier provision, however, is budget neutral, which means some physicians would be rewarded at the expense of others, Bennett said. Medicare plans to begin applying the modifier to some physicians’ pay in 2015 and to all physicians in 2017. Medical groups will track the provision as it goes through the federal rule-making process, Hedstrom said. “The good news about a rule is that there is an open period for comment, and I assure you, this one will get blasted out of the water,” she added.
The law also requires the U.S. Department of Health and Human Services (HHS) to submit a national quality improvement strategy to Congress. Key issues will include how it’s structured and how quality data are gathered and measured, Brereton said.
The law’s quality provisions, combined with the nomination of national quality leader Donald M. Berwick, MD, to head CMS, send a message, Dr. Healy said: “The handwriting is on the wall for our specialty and other specialties that we must determine what works well and in the most cost-effective way.”