Nearly all otolaryngologists have been told about, seen a poster of or received an email from someone informing them that in 2015, the Centers for Medicare and Medicaid Services (CMS) will penalize physicians who do not comply with its Physician Quality Reporting System (PQRS). But David Niel-sen, MD, executive vice president and chief executive officer of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), can’t emphasize enough the fact that physicians need to begin complying now—not in three years.
Welcome to the new world of PQRS, a mandatory version of the Physician Quality Reporting Initiative that has been in place since 2007 but, as of 2010, was only in use by roughly 25 percent of eligible providers, according to CMS data. PQRS, like its optional predecessor, is a pay-for-reporting system that will give compliant physicians a 0.5 percent incentive payment for total Medicare Part B Physician Fee Schedule (PFS) charges for covered services (which means the incentive covers all payments from PFS, not just those applied to the services being reported).
The landmark Affordable Care Act (ACA) has gone a step further, however: Nonparticipating physicians will lose 1.5 percent of allowable Medicare charges beginning in 2015. The cut increases to 2 percent in 2016. Unfortunately, too many physicians believe that the 2015 deadline applies to preparing for the program, Dr. Nielsen said. In reality, 2015 is the first year the penalties will be levied, but the payment adjustment will be based on data from the 2013 reporting period, Jan. 1 through Dec. 31, 2013.
Support Systems Available
“It isn’t that physicians haven’t heard the message; it’s just that it’s coming in so fast and so furious that it just washes over them like a wave, and they’re not really internalizing it and understanding it,” Dr. Nielsen said. “We have to let the physicians know that as confusing and overwhelming as this may seem, we have some organization structure and support for them.”
AAO-HNS is working with CECity to promote PQRIwizard, a PQRS registry. Ariann Polasky, director of provider products for CECity, said the registry works like an online tax preparation program. It costs $299 and will collect, validate, report and submit the results to CMS, according to marketing materials for the tool. Other than using a qualified PQRS registry, there are two other options to report data to CMS. One involves using a practice’s or institution’s electronic health record (EHR) system. The other uses claims-based reporting.
Regardless of how they report, Polasky said providers must move quickly to ensure they avoid the penalties associated with noncompliance. She compared the process to e-prescribing, which caught some physicians off guard, despite years of advance notice, when they saw reductions in their Medicare payments for noncompliance.
To that end, Kylanne Green, executive vice president of health services for Inova Health System of Falls Church, Va., said most hospitals aggregate quality data by physician. But Polasky said it would be wise for individual physicians to find out if their practice is reporting PQRS measures. Otolaryngologists shouldn’t assume the EHR system they work with will automatically do the work for them, because the vendor may not have included or enabled a PQRI module. “You need to be your own advocate and make sure that the systems you have in place will do what you think they’re going to do,” she said. “Ask the question up front.”
Polasky added that, aside from determining how to report, physicians and practices need to choose what they will report. The CECity registry will work for otolaryngologists who choose to report on a measure group or three individual measures from a list of CMS-approved measures. Physicians who use the “individual measure” option must report on 80 percent of their eligible Medicare Part B fee-for-service patients.
“Measures have to meet certain specifications and standards and be ‘endorsed’ by [the National Quality Forum] and CMS before a doctor can get credit for complying with it,” Dr. Nielsen said. “One can’t just make up a measure and report on it. If doctors in hospitals are not providing the kind of care relevant to the endorsed measures for their specialty, then there is nothing on which they can report.”
Physicians and practices also have an option to report on grouped measures. There are different options for how many patients must be reported on, depending on sample methods, but the number typically ranges from 15 to 30 patients.
For the Greater Good
Physicians should not look at PQRS as the latest in a series of reforms “being done to them,” said Dr. Nielsen. Also, they shouldn’t fall into the trap of believing that deadlines will be repeatedly delayed, as has been the case with Congress’ approach to long-term fixes to the sustainable growth rate formula used to calculate Medicare payments. Instead, they should look to embrace quality improvement, keeping in mind that it betters patient care, especially given the fact that the inevitable trend toward value-based payments means that otolaryngologists who perform with better quality will be paid better.
“This is about patient care, making people better, improving public health,” Dr. Nielsen added. “No one would ever criticize a physician in his or her own practice for being more economically efficient and trying to manage a better business. So why can’t we apply that same attitude toward the national and global costs and bring those down?”