PQRI overhaul finds faults and inputs fixes for 2009

A chief medical officer with Medicare explains how the agency listened to doctors to improve and made easier a program that promises more reimbursement for the care you're already delivering to your patients.

The Physician Quality Reporting Initiative (PQRI) had some glitches when CMS rolled it out in 2007. The program, which offers financial incentives to physicians who report on certain quality measures, was criticized by many physicians who found the reporting cumbersome, the results erroneous or the reimbursement not worth the effort.

CMS listened to the feedback and re-designed various aspects of the program, including implementing fixes for issues that erroneously prevented internists from getting paid in 2007. The agency will re-run the 2007 data and anticipates that additional physicians who were impacted by data issues will qualify for the incentive.

William J Kassler MD
William J. Kassler, MD

Practicing internist William J. Kassler, MD, is chief medical officer for CMS’ New England Region and sits on the national leadership team for PQRI, reviewing the program several times a week by conference call. He discussed what went wrong and what CMS has done to resolve the problems for 2009 and beyond.

Q: What obstacles did CMS face before launching PQRI?

A: Congress passed the Tax Relief and Healthcare Act (TRHCA) into law in December 2006, and told us that we must have a PQRI program commencing in July 2007. We couldn't select only high-tech practices; we had to use a system that everyone could participate in. And we weren't given a budget to develop new analytic or IT systems.

Q: Why did some physicians not get paid despite qualifying for a bonus?

A: The IT infrastructure between physician offices billing software, clearinghouses and carriers was complex. We uncovered some analytic issues in the coding system. Quality data codes that the doctors were affixing to their claims were stripped from the rest of the claim in 6% of all claims submitted. Some of them were related to office software that couldn't handle [PQRI quality data] codes. We traced some data issues back to clearinghouses. In several instances, the carrier itself had to readjust its software. So in some circumstances the doctor did everything right, they got the measure right, but the system would strip the quality reporting code. We're re-analyzing 2007 data, and we expect more doctors will qualify for PQRI in 2007 and will be receiving a check for this time period in the fall of 2009.

Q: What other glitches occurred in the rollout?

A: The National Provider Identifier (NPI) was also an issue, with about 12% of PQRI claims in 2007 being unsuccessful because they did not have a valid NPI. Now that NPI is fully implemented, and physicians must use it to get paid, this is no longer an issue.

Q: What feedback did CMS receive from the first round of PQRI results?

A: First, we heard that the feedback report was difficult to interpret, and that the process to sign up for the feedback report was cumbersome and burdensome. We agreed to modify the system to be more useful to physicians. This includes conducting focus groups of practicing physicians to help us design a more user-friendly report.

Also, we heard that some of the measures are very complex, and doctors encountered some difficulty in coding those measures. The best measures are developed by practicing doctors in a format that is consensus-driven and evidence-based. When there is feedback with those measures, or there are issues brought to our attention about how the numerator or denominator is coded, we will send those back to the measure developers and broker those interactions. We are spending a good amount of effort working with ACP and the American Academy of Family Practitioners and others to develop enhanced educational outreach materials.

Q: What is CMS doing to make it easier for physicians to access feedback reports?

A: We are hoping to roll out a system whereby with a phone call to the Medicare Administrative Contractor (formerly known as the carrier), physicians will be able to request an e-mail of their feedback report without having to sign on to IACS (Individuals Authorized Access to the CMS Computer Services). We've stripped data that we were told is not relevant or helpful, to make it a more streamlined report and hopefully a better, more useful tool.

Unfortunately, we cannot offer real-time feedback. We heard the physicians loud and clear that more frequent feedback on PQRI would be very helpful, and we would love to be able to do that. But the infrastructure, resources and cost make real-time feedback prohibitive. For the foreseeable future, PQRI is going to be a retroactive calculation with some delay due to claims lag.

What we are doing is working with the ACP and AAFP to help internists develop mechanisms so they can track this information themselves in their offices.

Q: How can doctors get started now?

A: Internists can scan the 153 measures and choose three measures that make sense to their practices. Many measures only require annual reporting, so it's still not too late to begin. Internists may also want to consider reporting on a measures group, such as the diabetes measures group. Rather than report on three measures at the 80% level for the year, reporting a measures group can be done on 30 consecutive patients. (Find complete instructions on this in the April 2009 issue of ACP Internist.)

Physicians can choose to make an intensive effort for a relatively short amount of time, or they may just want to incorporate a protocol into their “superbill” and make it a routine and sustained effort. We have found that practices who involved the staff both at the front end and the back end of their office work-flow and who used a strategic approach to build in a process that identifies when a measure is reportable for a given patient have the most success.

Q: Is CMS planning to make participation mandatory?

A: We have no intention of making PQRI mandatory. This is a voluntary program with an incentive payment of 2% of the provider's Part B allowable charges. While it may not seem like a lot of money, it can be combined with an additional 2% incentive payment for electronic prescribing. Many doctors that I'm talking to are taking a second look at PQRI and electronic prescribing because they don't want to leave that on the table.