Whether relating to health outcomes, patient perceptions of care or organizational structure, quality metrics are playing an increasingly substantive role in Medicare payment and reimbursement. As Robert S. Lagasse, MD, explained at the 2016 American Society of Anesthesiologists Practice Management annual meeting, despite the limitations of these measures, the financial stakes for physicians have never been higher.
“Measures of quality, resource utilization, engagement of patients and families through electronic health records [EHR] technology, and clinical practice improvement activities will determine physician reimbursement,” said Dr. Lagasse, professor and vice chair of quality management and regulatory affairs, Department of Anesthesiology, Yale School of Medicine, in New Haven, Conn. “There is a lot of money at stake.”
Physician Quality Reporting System
The Physician Quality Reporting System (PQRS) is a quality reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care they provide to their Medicare patients.
While there are other advantages to quality metrics—clinicians can assess the quality of their care by comparing their performance to quality metrics benchmarks—perhaps the biggest incentive is financial. Physicians also can participate in PQRS in order to satisfy the clinical quality measure component of the Medicare EHR Incentive Program and avoid negative payment adjustments.
To participate in 2015 PQRS, individual EPs may choose to report information on individual PQRS quality measures or measures groups using Medicare Part B claims or qualified clinical data registry (QCDR). Qualified PQRS registry and electronic reporting using certified EHR technology (CEHRT) can be used by both group practices and individuals.
Physician anesthesiologists, certified registered nurse anesthetists and certified anesthesiologist assistants are on the 2016 list of EPs.
For claims reporting, individual EPs must report on at least nine measures across three National Quality Strategy (NQS) domains for at least 50% of their Medicare Part B Fee-for-Service patients.
As Dr. Lagasse reported, 2016 PQRS measures applicable to anesthesiologists include:
#76: prevention of catheter-related bloodstream infections;
#44: continued administration of β-blockers;
#130: documentation of current medications;
#226: tobacco use; screening and intervention;
#342: pain under control within 48 hours; and
#358: preoperative risk assessment.
NQS domains include:
person- and caregiver-centered outcomes;
communication and care coordination;
community, population and public health;
efficiency and cost reduction; and
effective clinical care.
EPs who submit quality data for less than nine measures, across less than three NQS domains or do not report on one cost-cutting measure will be subject to measure-applicability validation (MAV).
“If PQRS instructions are like the federal tax code,” said Dr. Lagasse, “then the MAV is like a federal tax audit.”
Like a tax audit, the MAV has financial consequences, which will determine the 2016 PQRS payment adjustment based on 2014 data.
Group practices must report on nine measures across three NQS domains for greater than or equal to 50% of the group’s Medicare Part B Fee-for-Service patients. If less than nine measures or three NQS domains are reported, the Centers for Medicare & Medicaid Services (CMS) will again apply the MAV.
The 2015 PQRS data submission window should have been in the first quarter of 2016 to avoid a penalty in 2017, said Dr. Lagasse.
Introduced in 2014, the QCDR reporting mechanism is not limited to measures within PQRS, nor is it limited to Medicare beneficiaries. Individual EPs who satisfactorily participate in 2015 PQRS through a QCDR may avoid the 2017 negative payment adjustment (–2.0%).
Group Practice Reporting Option
Group practices participating in the PQRS Group Practice Reporting Option registry may report via qualified registry, CEHRT or CMS Web interface (not via claims or QCDR). Using a shared tax identification number, participants report on quality measures in seven care/disease modules: care coordination/patient safety, chronic obstructive pulmonary disease, coronary artery disease, diabetes mellitus, heart failure, hypertension and ischemic vascular disease.
As Dr. Lagasse noted, however, these categories do not have anything to do with anesthesia.
“I participate in PQRS without sending any anesthesia measures or measures that have to do with the patients I’ve seen,” he said.
2016 Payment Adjustments
Eligible professionals and group practices who do not report data on 2014 PQRS quality measures will be subjected by CMS to a payment adjustment in 2016.
“EPs and group practices receiving a PQRS payment adjustment in 2016 will be paid 2.0% less than the posted Physician Fee Schedule amount for services rendered Jan. 1 to Dec. 31, 2016,” said Dr. Lagasse.
“This is serious,” he concluded, “so it’s important to do this right. There are at least three different systems that could potentially take your money away.”
Joseph William Szokol, MD, chairman of the Department of Anesthesiology at NorthShore University HealthSystem in Evanston, Ill ., said one of the biggest issues with quality measurements is their impermanence.
“The problem is that the bar keeps changing,” said Dr. Szokol. “A lot of the metrics are still looking at process rather than outcome measures. … It used to be value-based purchasing, and now we have the MIPS [Merit-Based Incentive Payment System] and MACRA [Medicare Access and CHIP Reauthorization Act of 2015]. It’s very much a moving target.”