Medicare's P4P program aims to improve care

For many physicians, their first real experience with pay-for-performance will be through the Center for Medicare and Medicaid Services' (CMS) Physician Quality Reporting Initiative (PQRI). In 2008, approximately 100,000 providers participated in the program. In 2009, along with the incentive payment (increased to 2%) the participation numbers are expected to grow. Facilitating that growth is the fact that in 2009, physicians may submit data via claims or via the new registry reporting method, greatly increasing the ease of participation.

For 2009, CMS has selected 153 quality measures developed through a national consensus process facilitated through the National Quality Forum and the Ambulatory Quality Alliance. The development of these measures included input from many stakeholders, including the American Medical Association and the Association of Health Insurance Plans. The addition of the registry reporting method encourages the collection of quality data for all payers. In other words, practices provide a sample of data that need not be limited to Medicare patients. CMS is qualifying selected clinical registries, some sponsored by medical professional associations, to facilitate data collection and reporting. In this way, CMS is encouraging real quality improvement, aligning incentives for physicians and establishing transparency in the system.

When the PQRI program began in 2007, claims based reporting was the only option. Although more than 100,000 providers submitted PQRI data using CPT II codes via their daily claims submission, only 52% (56,722) of those actually received payments (with an average payment of a little more than $600 for six months of data). One challenge with reporting through claims is that providers must report the data along with their billing data and without the opportunity to conduct data quality reviews prior to transmission. Also with this method, data collection is limited to Medicare patients only (unlike registry reporting explained further below) and physicians must learn to work with specialized CPT-II and G codes. Many of these issues have jumpstarted the involvement of some practice management systems and Electronic Medical Records (EMR), which are working to automate data collection for providers.

In August 2008, CMS selected 31 patient registries as qualified to perform PQRI reporting on behalf of physicians and other providers. Additional registries and an updated PQRI Toolkit are expected to be announced in the spring of 2009 on the CMS website. These registries vary in their intended audiences and clinical focus. For example, the Society for Thoracic Surgery enables measures relevant for cardiac surgery. Others are designed to serve specific health systems or geographic areas, such as the Presbyterian Health Care Services and the Wisconsin Collaborative. Others offer services across specialties and geography and include all 153 measures. In general, providers can choose a registry at any time during the calendar year, since PQRI data collection can be done retrospectively. However, to get the maximum benefit for quality improvement, practices are encouraged to use their registry throughout the year.

Improving Care

Performance registries are designed for data collection focused on improving care as well as reporting to CMS or potentially other payers. For measures groups reporting, CMS requires that only two of the minimum 30 consecutive patients be Medicare Indemnity insured, which differs from claims-based reporting where all patients must be Medicare Part B. CMS is encouraging physicians to collect and analyze data on patients, regardless of payer. Tools can include sophisticated benchmarking, reporting, and analytical capabilities as well as guidelines and patient education materials within the program. The ability to enter and to view this data at any point throughout the reporting year also means that practitioners can perform data entry or perform chart review retrospectively in a batch format. Data automation can help improve the accuracy and timeliness of the information collected while diminishing the cost of data collection.

How To Use a PQRI Registry

Each provider needs to report either one measures group (30 consecutive patients, including two Medicare Indemnity) or three individual measures (80% of Medicare Part B Claims) for tracking. For 2009 there are seven measures groups:

Diabetes (6 measures),

Chronic Kidney Disease (5 measures)

Preventive Care (9 measures)

Perioperative Care (4 measures)

Rheumatoid Arthritis (6 measures)

Back Pain (4 measures)

Cardiac Surgery (2 measures)