Mind your ‘P’s and Q’s’

Saturday, November 01, 2014 12:18 PM

PQRS could benefit practices and patient health

by Marilyn Rissmiller, senior director, Colorado Medical Society

Editor’s note: This piece is part of an ongoing series Colorado Medicine will publish about Medicare’s approach to cost containment and quality improvement.

With Medicare turning up the heat on quality-improvement programs such as PQRS (Physician Quality Reporting System), CPCI (Comprehensive Primary Care Initiative) and VBPM (Value-Based Payment Modifier), doctors might feel as if they are submerged inside a big, steaming pot of alphabet soup.

And while the analogy might not sound appetizing, many providers will sink or swim in this rapidly changing environment. Programs like PQRS are designed to alter Medicare compensation – with ramifications on the broader payer market that Medicare influences, the physicians’ competitive field, the fiscal health of their practices and (most important) the health of their patients.

Chances are good that if you’re already seasoned in the tenants of HIT (Health Information Technology) and EHR (Electronic Health Record) and Meaningful Use, your practice is already soaking in the data gathering and the elaborate system of incentives and penalties inherent in the Centers for Medicare and Medicaid Services’ (federal CMS) quality-improvement push.

Not to suggest that late adopters to these concepts are “up alphabet soup without a paddle,” but they will certainly be better equipped to face the roily waters of this payment sea change and even land ashore safely if they begin paddling their way toward the calmer waters of compliance.

Last month, Colorado Medicine teed off its series about the cost-containment and quality-improvement measures implemented by the federal CMS with an overview of how these different programs work together. (See “Aligning the big picture: Medicare incentives turn into penalties,” Sept.-Oct. 2014 edition).

This part of the series will take a closer look at PQRS – a key ingredient to stirring health care from a fee-for-service model to a system that encompasses the principles of evidence-based medicine, prevention and chronic-disease management.

As with the other pieces of the federal CMS’s strategy, PQRS aims to ultimately improve the patient experience of care and the health of populations, and cut costs in large part by improving the quality of available data. It does so by providing “carrots” for providers to report the data and “sticks” for not providing the data or for improving their measures.

Though the federal CMS’s logic in aligning these programs seems well-reasoned, it remains to be seen whether this approach will actually move the needle in improving clinical outcomes or reducing costs. What is certain, however, is that providers that don’t participate may feel a pinch in the not-too-distant future for their refusal to play. And in the case of PQRS, they might miss out on an opportunity to make their practices more effective and efficient and to help improve the health of entire populations.

What is PQRS?
Simply put, PQRS uses a combination of incentive payments and payment adjustments to report recording of quality information by eligible professionals. Launched in 2007, the program started as a pay-for-reporting program for collecting clinical quality measures.

“It didn’t matter how the data reflected on the practices, they just wanted you to report it,” said Devin Detwiler-Cunningham, an HIT quality improvement specialist at Telligen, a Des Moines, Iowa-based population health management company with offices in Englewood, Colo.

Detwiler-Cunningham works with individual practices on using their quality-based measures. Telligen is contracted by the federal CMS under the Quality Improvement Organization (QIO) Program to provide such consulting services at no cost to the practice. QIOs work with local health care providers in all settings of care on data-driven quality initiatives to improve patient safety, reduce harm, engage patients and families, and improve clinical care at the community level.

Though PQRS data started rudimentarily (in the beginning, most PQRS data was derived from insurance claims), Detwiler-Cunningham notes that it has evolved significantly in recent years. It now includes more than 300 measures – most written by the National Committee for Quality Assurance, a physician-led nonprofit dedicated to improving health care quality, or the American Medical Association.

These comprehensive measures – based on evidence-based best practices for care – range from rates of aspirin given at arrival for patients with acute myocardial infarction to flu shot percentages within a family practice. In recent years, the measures have branched out to such specialties as oncology, radiology and bariatric surgery.

“It’s a way to communicate evidence-based medicine and get it into the provider offices,” Detwiler-Cunningham said. “The move has been to go electronic, because EHRs are such a great tool.”

But while an EHR could make implementation of PQRS easier, the federal CMS has made efforts to accommodate practices that might not have taken advantage of EHRs yet. Detwiler-Cunningham notes that the federal CMS accepts the information in a number of ways, including claims, third-party registries and clinical registries. The hope is that through PQRS, the federal CMS could amass a growing body of data that will ultimately inform and improve care.

“It’s basically a carrot and a stick that encourages physicians to actually look at their data,” Detwiler-Cunningham said. “It encourages benchmarking and informs best practices.”

Incentivizing participation
The federal CMS launched PQRS with a bonus payment of 1.5 percent for successful participation based on the estimated total charges. On the reverse side, physicians who elect not to participate or are found to be unsuccessful during the 2013 program year will receive a 1.5 percent payment penalty, and 2 percent thereafter. (See chart: “PQRS incentives and penalties, page 20.”)

However, 2014 is the last year physicians can receive an additional incentive for participating in the PQRS Maintenance of Certification (MOC) program. Once that phase sunsets, physicians will be rewarded or penalized for falling on the right side or the wrong side of a clinical measures “bell curve.”

“Every single provider who bills and collects Medicare B is going to be graded in the bell curve,” Detwiler-Cunningham said. “Every doctor will be assigned a value modifier. If you are in the lower 7 percent, you’ll get penalized; if you’re in the upper 8 percent, you’re going to make more money. What’s going to happen is 85 percent of the providers are going to stay the same. Probably 8 to 10 percent will lose money and 8 to 10 percent will gain money.”

Hospitals are already accountable to similar quality-improvement measures from the federal CMS, such as penalties that essentially ding the institutions when their 30-day readmission rates creep above the acceptable norm. Likewise, PQRS holds doctors accountable for their performance in myriad quality measures.

Not only do providers stand to gain or lose money from PQRS, but the data gathered will be used to feed Physician Compare, the federal CMS’s consumer-oriented website that shows how doctors measure up with other doctors. In addition to being used by prospective patients seeking care, the site could also be utilized by practices looking to assess their competition.

“Providers are very competitive, so once they see they’re on the lower end of the bell curve, it’s incumbent on them to improve those numbers,” Detwiler-Cunningham said. “But the beauty of this program is that all of these measures can be improved upon. The data comes directly out of every physician’s EHR, claims or charts, so they have the power to change it or ignore it.”

Unlike the data collected by private insurers, PQRS comprehensively reflects how individual practices are doing – giving them a baseline for improving their operations and health of their patients. In the federal CMS’s grand scheme, the program encourages practices to make sure their patients are receiving chronic-disease management and preventative care.

Though PQRS is intended to improve care, Detwiler-Cunningham said it would theoretically reduce costs in the long run.
“If you can prevent colon cancer, it will save a lot of money. If you can prevent a diabetic or a heart-failure person from going to the hospital because their meds and chronic conditions are managed, that will save money.”

Since Medicare often leads the charge in payment reform, it’s possible that private insurers will inevitably follow the lead set by the federal CMS – potentially putting participating physicians ahead of the changes in payment reform.

However, not everyone is a fan of the federal CMS’s carrot-and-stick approach in rolling out PQRS. Even though he classifies himself as an “early adopter” of EHR and the federal CMS’s quality-improvement initiatives, Mark Hinman, MD, says he doesn’t like the punitive effect PQRS has on physicians who might not have the resources to incorporate such systems into their practices.

“These penalties are going to hurt the slower adopters the most,” said Hinman, a Longmont-based physician whose family practice has already reaped the benefits of EHR and quality-improvement programs such as PQRS. “They don’t have the funds to make the changes they need to do.” (Hinman’s success with PQRS is detailed in a sidebar to this article, “Patience pays off for Longmont practice, patients,” below).

The case for participating
Though Medicare’s reimbursements generally cover about 55 percent of billed services and the program constitutes a small portion of most private practices’ funding, it is critical to maintaining cash flow – particularly for internal medicine practices.

“A lot of people really like Medicare because you bill them and get paid electronically within two weeks,” Detwiler-Cunningham said. “It’s pretty straightforward. If you have a question, you call them and they answer you. In that way, they’re very good in terms of cash flow. A lot of private payers take 45-90 days to process a claim. That’s what some people like about Medicare, but again, in some cases it doesn’t even cover your overhead.”

Because of the growing frustration with Medicare’s low reimbursements combined with mandated carrot-and-stick programs like PQRS, Detwiler-Cunningham said she’s heard that some practices are threatening to stop seeing Medicare patients altogether. But doing so – or refusing to participate in PQRS and other quality-improvement programs – could only effectively remove practices from the competitive playing field or unfairly skew their results in the public eye.

Savvier Colorado practices such as Hinman’s have already embraced PQRS and other federal CMS programs, and made it work to their practice’s advantage.

And though the benefits of PQRS and likeminded programs might not be apparent in the short run, they will pay off in time in the form of improved efficiencies and patient health. Though it may be too late for lagging practices to realize the incentives of participating in PQRS, they could still avoid future penalties and prepare themselves for the future of health care reimbursement by getting on board.

If those reasons aren’t enough, Detwiler-Cunningham asked physicians to consider how data-driven programs like PQRS essentially collect and distribute information that fundamentally belongs to the patients.

“The patient should be able to access their record no matter where they are,” she said. “It’s not the doc’s record anymore, it’s the patient’s. It needs to be documented so the patient can actually read it and share it.”

Medicare PQRS incentives and penalties
2013: 0.5% incentive (performance year for 2015 penalty)
2014: 0.5% incentive (performance year for 2016 penalty)
2015: -1.5% penalty
2016: -2.0% penalty

For more information about the Quality Improvement Organization, visit www.QIOProgram.org.

Patience pays off for Longmont practice and its patients with PQRS-related efficiencies

Longmont family practice physician Mark Hinman, MD, was an early adopter of the Electronic Health Record (EHR) system decades before the acronym and the term were commonly used in health care circles.

In fact, when the Hinman joined his father John Hinman, MD, at his small family practice in 1993, the father-son duo built their own EHR from a word processing system because “a good one wasn’t available at the time,” said Hinman.

“We saw the benefits right away,” Hinman recalled, citing legibility and ease of typing as the most immediately obvious benefits.

“All records were easy to find,” he said. “It helped us organize things and track immunizations. It worked very well.” Hinman remembers being able to check medical records from his home during late night calls rather than driving back to the office – a practice almost everyone takes for granted now.

Eventually, better technology caught up with the practice, which recruited Aprima Medical Technology to upgrade its EHR in 1996. To fully utilize its new tools, the practice established its own diabetic registry and began to more closely assess its cardiovascular patients through EHR.

Fast-forwarding more than 20 years, the elder Hinman is retired and still active in the community, while the younger Hinman remains at the cutting edge of EHR implementation at the two-person practice (Hinman now serves roughly 2,500 patients with Leila Hanag, MD).

The practice’s long-standing embrace of EHR enabled it to more easily provide the kind of data that the Centers for Medicare and Medicaid Services (federal CMS) recently began mandating from health providers. When the federal CMS announced incentives for reporting medical data, through the Physician Quality Reporting Systems (or PQRS), the Longmont practice was more than prepared.

“We were actually involved with taking some of the early steps already, so it wasn’t really a big stretch for us for getting ready for PQRS,” Hinman said.

Many physicians grouse about the federal CMS’s data-driven quality-improvement measures, which provide incentives for participation and enforce penalties for non-compliance. They also voice concerns about the “hassle factor” of gathering and providing the information to the federal CMS – not to mention staying within the bell curve of best practices to avoid additional penalties.

Hinman said his practice has not only improved efficiencies through the data gathering, but has also used the data to improve the health of its patients.

“It’s just a matter of learning to collect the data and use it to actually make improvements,” he said. “It takes a period of time to learn how to do that efficiently.”

For example, the EHR helps the practice follow up with diabetic patients whose hemoglobin levels fall within a certain range. “We share the information and teach [patients] how to use it. That way, they have a better guideline of how to better control their diseases and will ultimately have fewer complications down the road.”

Though Hinman’s practice received some monetary incentives for participating in the federal CMS’s PQRS program, he believes the benefits of using data transcend higher reimbursements.

“Again, we’re already using quality measures already, so I’m not sure if the incentive program added that much to our patients’ health beyond what we were already doing,” he said.

Though the benefits of embracing technology to inform best practices and evidence-based medicine and prevention may require some initial investment and “sweat equity,” Hinman insists the payoff is great for practices and patients alike.

“In preparing for the future, we’ll need to be better able to manage groups of patients – and we’ll need more registry function in order to do that,” he said. “I think there’s no way to do it with the paper record. We need a computer to pull data from and have it actually work for you. The front end – getting people into the system – is where it takes the most time and energy. But it’s the backend where you’ll see the rewards. My recommendation is to stick with it and the efficiencies will start showing up.”