Thursday, December 11, 2008

Why, why ... PQRI?

The next phase of the PQRI program will start on January 1. I doubt, though, that many internists are wishing it a Happy New Year.

The PQRI, which was authorized by Congress in 2006, is the Physicians' Quality Reporting Initiative, the federal government's first foray into pay-for-performance for doctors. Starting on July 1 through December 31, 2007, physicians who agreed to voluntarily report on selected quality measures were promised they could earn Medicare bonus payments of up to 1.5 percent of total allowed charges.

By the federal government's own account, the program was a less than a resounding success. The Centers for Medicare and Medicaid Services (CMS), the agency that administers the program, reports that "approximately 16 percent of eligible professionals participated (submitted at least one quality data code) in the program. Of those who participated, just over half were successful in meeting the program and reporting requirements and as a result received an incentive payment."

CMS acknowledges that there were many problems with the program, including claims-based reporting mechanisms issues, National Provider Identifier (NPI) numbers not being included on the claims forms, incorrect quality reporting data or claims submission errors and the content of the feedback reports to physicians.

It promises to do better in 2009.

In my mind, the agency will have to do a lot better. The way the PQRI program was designed and implemented almost seemed designed to discredit the idea of P4P among (already skeptical) physicians. Successful quality improvement programs provide regular feedback to clinicians on how they are doing. Rewards for reporting should be greater than the costs and hassles of reporting. The rewards should be predictable (if I do x, I will receive y). And the timing of providing the rewards should be closely linked to when the reporting took place.

None of this was the case with PQRI. PQRI physicians largely were kept in the dark about how they were doing. The maximum bonus payments likely didn't even cover their costs. Physicians didn't receive their performance-based payments, if they received anything at all, until as much as six months after the reporting year closed.

Internists now have to decide whether to give the PQRI another go in 2009. This time, the stakes are higher: successful reporting can result in bonus payments of up to 2 percent of allowed charges. ACP has extensive resources on the PQRI to help you decide, which are being updated for the new program year.

Despite the problems with PQRI, I believe that performance measurement and reporting are here to stay. Medicare views the PQRI as one of the first steps towards value-based purchasing, as do key legislators like Senator Max Baucus (D-MT) and Chuck Grassley (R-I0). Done correctly, reporting on quality measures may help internists deliver better care to patients - and earn higher payments for doing so.

Today's questions: Did you participate in the 2007 and 2008 PQRI programs? Why or why not? What was your experience if you did - and how can it be improved? Will you participate in 2009?


Jay Larson MD said...

Did not use PQRI in 2007 nor 2008 and do not plan to use in 2009. I have heard horror stories about the process. PQRI, as set up, is not valuable for my patients nor myself.

With that said, I do use Diabetes Quality Care Monitoring System (DQCMS) provided for free by the State of Montana. The program tracks 16 aspects of diabetes care. DQCMS has search features and highlights overdue diabetes services at point of care. At any time a summary of all patients in the system can be printed. Every quarter, summary results are sent into the State of Montana. The State of Montana then returns a comparative report to show how a physician is doing compared to other providers using the system.

If PQRI had the same features of DQCMS, I would use it in a heartbeat.

The Happy Hospitalist said...

I reported. Of almost 20 internists in my hospitalist group, I was the only one who successfully met the qualifications. It's nothing but a giant game. If you know how to report, that is far more important than what you report.

In it's current form, the reporting is a joke. BTW, I earned $1,100 for knowing how to play the game.

Chump change for all the effort it took me for documenting and the countless hours my billing company spent submitting the claims.

Anonymous said...

Yes, the PQRI process stinks, and the payback is minimal, but CMS will be shifting to pay for performance in the future -- rather than pay for reporting -- and providers would be well advised to get up and running with PQRI, work to get the kinks out of the system, so that when true P4P goes live (and it's virtually certain that it will) there will be no fear of technical noncompliance and loss of incentive payments. The cost-benefit analysis of whether to participate in PQRI needs to include that future component.

Dan said...

Evidence-based medicine is where the health care provider applies statistically significant and relevant evidence acquired through quality and valid clinical trials utilizing the scientific method.

The health care providers assess the risks and benefits of how they choose to treat or not to treat their patients. This paradigm of a practicing health care provider is to better predict the outcomes of their treatment of their patients. Such providers recognize the need for quality in medicine and place tremendous value on their patients' lives.

This paradigm of restoring the health of others protects public health.

There are three areas of evidence-based medicine:

1. Treat patients according to what is reasonable and necessary based on the evidence that exists regarding the treatment options health care providers select.

2. Health care providers review this evidence in order to judge and assess the best treatment for their patients.

3. Recognize that evidence-based medicine is in fact a movement that emphasizes the usefulness of this method to practice medicine.

Two types of evidence-based medicine:

1. Evidence-based guidelines- Policies and regulations are produced to ensure optimal health care.

2. Evidence-based individual decision making- This is how restoring the health of others is practiced by the health care provider.

This is the preferred way to practice medicine instead of medical guidelines, which are created from a combination of clinical studies in which conclusions are drawn to reflect national standards of care for a particular disease state.

Guidelines were implemented during the 1980s. At times, these guidelines are privately sponsored, which makes them unreliable due to bias and without independent systematic review or quality considerations by others.

Unlike evidence-based medicine, guidelines can have major flaws and inaccuracies due to toxic factors used to create such guidelines. In fact, most doctors do not follow medical guidelines, yet are rewarded by programs such as Medicare if they do follow medical guidelines that are established.

Dan Abshear

marcsf said...

Physicians should use "value based" purchasing and drop out of Medicare and all insurance plans and go cash only. Then we will see some sensible changes to the system!!!!

Arvind said...

Did not participate in 2007 or 2008 after attending at least 2 educational session, simply because I figured the potential bonus was far too little for all the cost and effort required to implement claims-based reporting.

I do not plan to do it until the data collection process is undertaken by CMS and is not claims-based. On a busy day, one cannot expect a physician to be able to code so many items; not to mention taking away attention from the care process to doumenting these codes.These games are good for institutions that have dedicated workers who take care of all the "dressing" up of claims necessary to qulaify. If the Senators cling to this model to establish a "value-based" purchase of health care, most small practices will be out of business or out of Medicare.