PQRS Moves From Carrot to Stick

In 2007, the Physician Quality Reporting Initiative was started as part of the Tax Relief and Health Care Act of 2006. In 2010, the name was changed to the Physician Quality Reporting System (PQRS). It is set up to provide a financial incentive to physicians and physician extenders.

“PQRS was put in place by the Centers for Medicare and Medicaid Services (CMS) as part of their efforts to attach a value to the healthcare provided,” says Bettina Berman, RN, MPH, CPHQ, project director for quality improvement at Thomas Jefferson University’s School of Population Health in Philadelphia. “PQRS is a group of quality metrics being used by physicians to report on their practice. Currently, you can get an incentive payment for participation.”

Small Incentives, Big Work

Some practices have declined to participate in the PQRS program because of what many viewed as a small incentive for quite a bit of work. For example, a recent article on 2011 participation published in American Medical News found that while the average payment was $5,463 for endocrinologists, the lowest payment was 37 cents. This may be one reason why only one eligible provider in three participated.

“One huge problem with PQRS is that compliance can be time consuming,” says Bradley Scheel, practice administrator for Raleigh Endocrine Associates in Raleigh, N.C. “It means paperwork and documentation that is often not in line with what a doctor does on a daily basis. If the doctors put the burden on someone else in the practice, that means they are spending money and time on things other than patient care.”

There is also some concern about whether PQRS is ready for prime time and how that might have adverse effects on providers. “While PQRS is a lot better than it was, there is still a long way to go,” says Ardis Hoven, MD, current president of the American Medical Association (AMA). “If you look at the success rate of those currently involved, it has not been very high. That indicates a problem with the system.”

However, in 2015 there will be changes, and the carrot is being replaced by a stick. At that time CMS will institute what it is calling the PQRS negative adjustment. Failure to qualify or participate will result in a 1.5% penalty based on total Allowable Medicare Charges. That rises to 2.0% in 2016 and beyond.

2015 Penalties Based on 2013 Performance

One of the concerns is that many physicians do not realize the 2015 payment penalties are based on 2013 performance. So, practices have only until Dec. 31, 2013 to avoid taking the hit two years later.

“If you do not participate in 2013, you obviously do not qualify for this year’s .5% bonus,” says Lawrence Ward, MD, MPH, FACP, vice chair for clinical affairs and quality in the Department of Medicine at Thomas Jefferson. “However, you will also receive the penalty later on. While not participating can have a neutral impact this year, the impact in 2015 may be much worse.”

Th ere are indications that most practices may not be ready. Th e American Medical News noted that of those endocrinologists who participated in PQRS for 2011, around 18% did not qualify for the bonus. Between those not participating, and the group that did not qualify, perhaps as many as 72% of endocrinologists could be looking at a penalty in 2015.

So, with only a few weeks left in the year, what can a practice do now to salvage 2015? Depending on how your specific practice operates, there are still a few alternatives.

Ways to Report Quality Measures

“There are a number of ways to report quality measures,” says Jennifer Gasperini, senior group governmental affairs representative with Medical Group Management Association’s Washington, D.C., office. “Whether you participate through claims, a qualified registry, or have a qualified electronic health records system (EHR), you can still report in 2013 to avoid a 2015 penalty. Information on this and the other available ways to qualify are available at the CMS website.

Each of these options does require that a certain number or percentage of your patients be included in reporting to qualify for the extra money. A practice might be able to get the incentive and qualify for 2015. However, because of the work required to compile this information, it may be too late to start and most likely will only be useful to the practice if the method is already in use.

If none of these other options is available, CMS has put in place one last opportunity to avoid the sanctions in 2015. A practice can report one indicator on one patient seen before Dec. 31, 2013. Although that won’t mean any extra money, it does give practices additional time to put future alternatives in place. All of those interviewed see this as being a one-time off er from CMS, and they are very unlikely to have this in place in 2014.

Penalties Add Up

Although most of the focus has been on PQRS and the penalties directly attached to that program, other financial issues are involved.

“Participating in PQRS will fulfi ll the quality indicator section requirements for meaningful use,” notes Ward. “In 2015, practices with more than 100 eligible providers will be subject to penalties under the Physician Value–based modifi er; and those with 100 will follow by 2017.”

These penalties from different programs are cumulative. For example, those who don’t qualify under PQRS this year miss out on the 0.5% bonus. However, when the penalty phase begins in 2015, they will incur a 1.5% penalty. Additionally, they may be subject to a 1.0% penalty for failing to participate in the EHR incentive program (Meaningful Use). All programs involved will total 6% of Medicare reimbursement at risk by 2016.

“This overlap is not only a down side, because you can also use it to spread the costs around a little,” says Jonathan D. Leffert, MD, managing partner of North Texas Endocrine Center in Dallas. “Because of the push toward electronic records, for instance, adding the infrastructure for PQRS is largely a marginal cost.”

If you manage to rescue your practice during the waning days of 2013, early 2014 is the time to begin working toward a system that can be in place so you aren’t running around putting out fires later in the year. What resources are available to the practice?

What to do in 2014?

One of the best places is the “getting started” part of the CMS PQRS website (www.cms.gov). It also has a help desk available to answer questions. In addition, the AMA has a wide-ranging area about this on its website. Other organizations, such as the Medical Group Management Association, have information and may present seminars from time to time. Perhaps the best resource is colleagues who have already gone through the process.

“When we started looking into this, it seemed very daunting,” says Leffert, whose small practice includes two physicians, two nurse practitioners, and a dietician. “Physicians are already busy seeing patients and dealing with day-to-day operations. When you add these extra loads, there is plenty of reason to put it off for a while. As with many things in business, once you find the process that best fits your particular situation, it isn’t really an overwhelming task.”

Add in other stressors such as the changeover to the International Classification of Diseases, Tenth Revision, the rise of Accountable Care Organizations, and implementation of the Patient Protection and Accountable Care Act, it is small wonder that practices let PQRS slide until the last minute.

“All carriers are looking at participating or instituting some form of this program sooner rather than later and will favor those practices that comply,” says Scheel. “The era of massive data collection is already here. If you don’t want to comply, perhaps the only alternative is a concierge practice that only accepts cash.”

— Ullman, RN, MHA, is an Indiana-based freelance writer with nearly 30 years of experience.

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