This is the second in a two-part series summarizing the highlights of the Proposed Medicare Physician Fee Schedule Rule for calendar year 2011 and recent legislative updates, which together will help shape the structure of the 2011 Medicare Physician Fee Schedule.
PHYSICIAN QUALITY REPORTING INITIATIVE
Some of the most significant changes to the PQRI are enacted through the Patient Protection and Affordable Care Act known as the Affordable Care Act (ACA) which together with the Health Care and Education Reconciliation Act (HCERA) forms the comprehensive health care reform bill.
INCENTIVE PAYMENTS & PENALTIES
Eligible professionals who successfully report PQRI measures in 2011 will qualify to earn an incentive payment of 1.0 percent of their total estimated allowed charges for Medicare Part B Physician Fee Schedule (PFS) covered professional services ( this does not include drugs or labs) furnished during that same period. For 2012 through 2014, successful reporters may earn an incentive payment of 0.5 percent.
Beginning in 2015, eligible professionals who do not successfully report PQRI measures may be subject to a payment adjustment or penalty. In 2015, the penalty for not successfully reporting is 1.5 percent, this penalty rises to 2.0 percent for 2016 and each subsequent year.
Additional Incentive Payment
The ACA defines a MOCP as a continuous assessment program, such as a qualified ABMS MOCP, or an equivalent program (as determined by the Secretary), that advances quality and the lifelong learning and self-assessment of board certified specialty physicians by focusing on the competencies of patient care, medical knowledge, practice-based learning, interpersonal and communications skills and professionalism.
MOCPs must require a physician to:
Under the ACA, a qualified MOCP practice assessment is an assessment of a physician’s practice that includes:
In addition, to qualify for the additional incentive payment, the MOCP Program is to submit the following information to CMS on behalf of the EP:
In the 2011 proposed rule, CMS addresses the ACA’s additional PQRI incentive payment and proposes to require the following:
Organizations that want to participate as an MOCP and enable their members to be eligible for the additional PQRI incentive program will need to go through a self-nomination process by January 31, 2011. MOCPs will also need to provide to CMS signed documentation from the EP that the EP wants to have their information released to CMS.
Other CMS proposals for the 2011 PQRI include the proposed PQRI reporting mechanisms, the proposed criteria for satisfactory reporting, the proposed measures and measures groups, creating an informal appeals process, providing timely feedback reports to EPs and establishing the new Physician Compare website.
While proposing to retain the claims-based reporting option in 2011, CMS states their intention to phase-out or significantly limit this PQRI reporting option after 2011 thus allowing CMS and EPs to devote available resources towards maximizing the potential of registries and EHRs for quality measurement reporting.
In particular, CMS identifies the following limitations inherent with claims-based reporting:
CMS points out the problems associated with reporting QDCs through claims-based reporting, a system developed for billing purposes, are not an issue when QDCs are reported through registries. Furthermore, in contrast to the low rate of success for claims-based reporting, over 90% of EPs using the registry-based option in the 2008 PQRI qualified for the incentive plan. CMS reports the number of qualified registries has increased since 2008 and they expect additional registries to become qualified in future years.
PROPOSED CRITERIA FOR SATISFACTORY REPORTING
Reporting of Individual Quality Measures for Individual EPs
In previous years, EPs reporting individual quality measures through claims-based reporting were required to meet a threshold of reporting at least three measures (or one or two measures if less than three measures are applicable to the services of the provider) in at least 80% of the cases in which the measures apply. In the proposed rule, CMS notes that a major reason for the low success rate of claims-based reporting was the failure of the EP to report at the required 80% threshold. Therefore, CMS proposes lowering the reporting threshold for claims-based reporting of individual measures to 50% in 2011.
CMS is not proposing to lower the reporting threshold for EPs reporting individual measures through qualified registries or EHRs, EPs reporting through these mechanisms must report on at least three measures for at least 80% of the FFS patients receiving services where the measure applies.
PROPOSED 2011 CRITERIA FOR REPORTING ON INDIVIDUAL QUALITY MEASURES
Claims-Based Reporting – 6 or 12-Month Reporting Period:
Registry-Based Reporting – 6 or 12-Month Reporting Period:
EHR-Based Reporting – 12-Month Reporting Period:
Reporting of Measures Groups for Individual EPs
PROPOSED 2011 CRITERIA FOR REPORTING ON MEASURES GROUPS
Option #1 - Claims-Based Reporting 12-Month Reporting Period
Option #2 – Claims-Based Reporting 12-Month Reporting Period
Option #3 – Claims-Based Reporting 6-Month Reporting Period
Option #4 – Registry-Based Reporting 12-Month Reporting Period
Option #5 - Registry-Based Reporting 12-Month Reporting Period
Option #6 – Registry-Based Reporting 6-Month Reporting Period
Established in 2010, the Group Practice Reporting Option (GPRO) allows for group practices of 200 or more practitioners to participate in the 2010 PQRI as a group with the incentive payment provided to the group rather than the individual. CMS is proposing to continue the GPRO I option, for group practices of 200 or more practitioners, in 2011 and to include a new group reporting option, GPRO II, for group practices with 2 to 199 practitioners.
PROPOSED MEASURES & MEASURES GROUPS
According to CMS all 2011 quality measures and measure specifications including instructions for reporting and identifying the circumstances in which each measure is applicable will be published on their website no later than December 31, 2010.
PQRI INFORMAL APPEALS PROCESS
ASCO contrasts the lack of meaningful oncology performance measures in the PQRI with the current 84 clinically relevant performance measures in the QOPI program and expresses their willingness to work with CMS staff on the PQRI.
CMS is required by the ACA to establish a Physician Compare web site by January 1, 2011. The website is to include information about physicians enrolled in the Medicare program and providers who participate in the PQRI. In 2011, CMS proposes to post information on EPs and groups who successfully participate in PQRI, CMS will not post EP or group performance information for the 2011 PQRI.
Starting January 1, 2013 CMS has to implement a plan for making information on physician performance public on the Physician Compare Web Site. The ACA requires that the measures for public reporting of physician performance include, to the extent practicable, the following:
With regard to the Physician Compare web site, the ACA requires the assurance of patient privacy, input from multi-stakeholder groups, and taking into consideration the plan to transition to value-based purchasing. The ACA also authorizes CMS to establish a demonstration program by January 1, 2019, to provide financial incentives to Medicare beneficiaries who are furnished services by high quality physicians.
In the 2010 final rule, CMS eliminated the payment for consultation codes (with the exception of telemedicine consultation codes) effective for dates of service on and after January 1, 2010. Providers were instructed instead to report either a new patient visit code or established patient visit code for office/outpatient services, or an initial hospital care visit or subsequent hospital care visit for inpatient services.
In determining to eliminate the consultation codes, CMS cited the desire to reduce confusion and the administrative burdens associated with filing these services and their belief that that no specialties would see their revenues decline by more than 3% due to the change.
In April 2010, 17 specialty societies participated in the AMA’s survey of Medicare’s elimination of consultation codes. Out of 7,781 respondents, about 5,500 completed most of the questions. The results of the AMA survey, shown below, illustrate that revenue losses are considerably higher than that predicted by CMS.
A June 18, 2010, letter sent to CMS by the AMA and thirty-three specialty societies, calls for CMS to review and revise their policy of eliminated consultation codes to avoid further financial losses to practices leading to the reduction of services provided to Medicare patients and the subsequent deterioration of coordination of care for these patients.
In the 2011 proposed rule, CMS solicits comments on the perspectives of physicians and nonphysician practitioners caring for Medicare beneficiaries under the current PFS policy since the elimination of payment for consultation services.
ASCO also urges CMS to reverse its current policy and resume payment for consultation codes under Medicare. ASCO reports that the elimination of consultation codes has resulted in an inequitable situation for oncologists and other sub-specialists who must frequently consult with patients with complex medical histories.
According to ASCO, the redistribution of value from the eliminated consultation codes to the new and established patient E/M services is unfair and inequitable, resulting in decreases in payments to oncologists in excess of 25% for these services. ASCO voices their concern that the policy is adversely impacting access to care.
ELECTRONIC HEALTH RECORD INCENTIVE PROGRAM
The Medicare and Medicaid EHR incentive programs provide incentive payments for the meaningful use of qualified, certified EHRs to achieve health and efficiency goals. The EHR incentive program final rule was published on July 28, 2010 and can be accessed on the CMS Medicare and Medicaid EHR Incentive Programs Web Site
These new programs, which begin in 2011, are separate from other CMS programs such as the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU), e Prescribing and PQRI. Nevertheless, ACA requires CMS to move towards integrating the reporting on quality measures under PQRI with the reporting requirements for meaningful use of EHRs.
In the proposed 2011 rule, CMS states their intention to include ARRA core clinical quality measures in the PQRI program and requests comments on how to align the EHR and PQRI measures, and how the plan for integration will optimally improve quality of care for individuals and provide meaningful use of EHRs.
CMS clarifies that EPs who are eligible to participate and qualify for the EHR Incentive Program for calendar year 2011, may not receive a separate, additional Medicare eRx Incentive Program payment. Nonetheless, physicians who receive incentives under the EHR Incentive Program for calendar year 2011 could still be subject to a penalty applicable in 2012 for not participating and being successful electronic prescribers in the eRx Incentive Program in 2011.
The eRx Incentive Program was authorized by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), and began in 2009. The eRx and PQRI are separate incentive programs and EPs may choose to participate and earn incentives in either or both of these programs.
Under the eRx Incentive program in 2011, successful electronic prescribers may earn an incentive payment equal to 1.0% of the total estimated Medicare Part B PFS allowed charges for all covered professional services furnished during the 2011 reporting period. For 2011, CMS proposes maintaining the reporting period to be the entire calendar year (January 1, 2011 – December 31, 2011).
CMS proposes to continue the 2010 e-prescribing reporting requirement in 2011, whereby EPs are required to report the prescribing eRx measure for at least 25 unique electronic prescribing events in which the measure is reportable by the EP during 2011. Proposed reporting mechanisms for 2011 include claims-based reporting, registry-based reporting and EHR-based reporting.
Under the proposed rule, the names of EPs and group practices who are deemed to be successful electronic prescribers for the 2011 eRx Incentive Program, whether they qualified for the incentive payment or not, will be posted on the Physician Compare Web site that CMS is required to establish by January 1, 2011.
The proposed rule also includes criteria for applying the 1.0% eRx penalty in 2012 for EPs and group practices that are determined to be unsuccessful e-prescribers. CMS proposes to make a determination of whether an EP or group practice is a successful e-prescriber based on the 6-month reporting period of January 1, 2011-June 30, 2011.
CMS states that the 6-month reporting period for the 2012 penalty will enable them to determine whether an EP or group practice is a successful e-prescriber prior to January 1, 2012, and thus allow them to apply the penalty in 2012 concurrent with claims submission.
CMS proposes that the reporting period for the 1.5% 2013 eRx penalty be the 2011 eRx reporting period of January 1, 2011 through December 31, 2011.
Both ASCO and the AMA disagree with CMS’ assertion that, “matching the criteria that will be applied for the 2013 penalty with the criteria that will be applied for the incentive in an earlier year would be the most effective means of encouraging EPs and group practices to adopt and use electronic prescribing systems since anyone who does not qualify for an incentive in 2011 would be subject to a payment adjustment in 2013.” In addition, in fact, the AMA states CMS’ proposal conflicts with the intent of the law.
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