Physician Quality Reporting System Research Articles

The National Commission on Physician Payment Reform: Recalibrating Fee-for-Service and Transitioning to Fixed Payment Models

The National Commission on Physician Payment Reform: Recalibrating Fee-for-Service and Transitioning to Fixed Payment Models

Maintenance of certification: How does it affect cytopathologists?

Maintenance of certification: How does it affect cytopathologists?

Electronic Health Records, Registries, and Quality Measures: What? Why? How?

The transition from volume-based healthcare to value-based care is advancing via the reporting of quality measures, initially as a part of "pay for performance" within Medicare's Physician Quality Reporting System (PQRS) initiative. However, "value-based purchasing" requirements within the Affordable Care Act will increase the percentage of reimbursement linked to the reporting of quality measures. Currently, only five PQRS measures are relevant to wound care, and the venous ulcer care measure will be retired this year. PQRS measures in wound care can only be reported via claims or qualified patient registries, and no wound care measures are endorsed by the National Quality Forum (NQF). The recent Health Informational Technology for Economic and Clinical Health (HITECH) Act promoting the adoption of electronic health records (EHRs) requires quality reporting by clinicians wishing to access EHR adoption money. These clinicians will be able to comply with the next stage of "meaningful use" of EHRs, beginning in 2015, by submitting data to a qualified registry, and registry submission may eventually be required by Medicare for reimbursement of some wound care products and procedures. Other specialties are using registries to track adverse events, measure compliance with practice guidelines, and for comparative effectiveness data. Evidence-based measures should be developed as electronic measures that can be submitted directly from the clinicians' EHR. New wound care measures should undergo testing for NQF endorsement. The not-for-profit U.S. Wound Registry is a qualified patient registry that is available for PQRS reporting, measure testing, and future registry submission requirements. The lack of tested wound care quality measures threatens the entire wound care industry, as quality-based reimbursement is not limited to physician payment. Quality measures are an increasingly important part of many Medicare payment systems, including those for acute care hospitals, hospital-based outpatient wound care departments, and accountable care organizations.

APA Supports New Complex Chronic Care Management Codes

Back to table of contents Previous article Next article Government NewsFull AccessAPA Supports New Complex Chronic Care Management CodesMark MoranMark MoranSearch for more papers by this authorPublished Online:30 Oct 2013https://doi.org/10.1176/appi.pn.2013.11a17AbstractA proposed Medicare rule, issued in August, addresses regulatory and payment policy issues but does not include the fee schedule. A final rule with the fee schedule will be issued this month.APA is endorsing the government’s move toward incorporating “complex chronic care management codes” as part of the Medicare fee schedule for 2014.In response to a proposed rule issued by the Centers for Medicare and Medicaid Services (CMS) in August, then-APA Medical Director James H. Scully Jr., M.D., told CMS in a letter that the codes can create a means for compensating physicians for non-face-to-face services they provide to patients with complex chronic conditions.(The proposed rule by CMS was issued in August and addresses a variety of regulatory and payment policy issues, but does not include the 2014 fee schedule; a final rule, with the fee schedule, is expected this month. Look to Psychiatric News for coverage.)“APA strongly favors compensating physicians for the non-face-to-face care management, including, but not limited to, team conferences, telephone calls, and patient education they provide to Medicare beneficiaries suffering from chronic care conditions,” Scully wrote. “We commend CMS for moving in this direction, which we believe is a starting point. These codes cross an important barrier in not requiring face-to-face time. We support CMS’s proposal to utilize the parameters described in the CPT guidelines to identify patients eligible for complex chronic care condition management services. A disproportionate share of Medicare beneficiaries suffering from two or more chronic conditions are suffering from a mental illness as shown in CMS’s analysis of Medicare claims for patients with multiple chronic conditions.”But Scully also said that the conditions currently required for billing the newly proposed complex chronic care management service G codes are unlikely to capture the non-face-to-face care management work many psychiatrists are performing for some of Medicare’s most chronically ill beneficiaries.“Among the population of Medicare beneficiaries who comprise the severely and persistently mentally ill, our members often function additionally as primary care physicians, coordinating all or most of this population’s health care,” he wrote. “We urge Medicare to design complex chronic care management codes that our members can use when coordinating the health care of the chronically mentally ill Medicare population. This necessitates the design of complex chronic care management codes that have broader conditions of use, such as the two existing non-face-to-face CPT codes. We prefer the CPT codes because their use permits use of CPT guidelines and, consequently, other payers’ likely adoption of these codes.”Scully also expressed support for the adoption of the psychiatry CPT values, reviewed and approved earlier this year by the Relative Value Update Committee (RUC) for the 2014 Fee Schedule. “Adoption of the RUC recommended values is necessary to correct the current rank-order anomaly that exists between the psychiatric diagnostic evaluation with medical services (90792) and the psychiatric diagnostic evaluation (90791), which does not include medical services,” Scully wrote in a September 5 letter to CMS. “A disparity in payment was created by the adoption of RUC-recommended reductions in practice expense values for only 90792. The inequitable result of this is that psychiatrists and advance practice nurses have been paid less this year for doing more work with more complex patients. We believe this inequity created inappropriate incentives on the clinical level. This issue will be resolved if CMS adopts the RUC recommended practice expenses for the 90791.”Scully also urged the government to adopt new values for CPT codes for psychiatric services, as recommended by the RUC. Other issues Scully addressed included proposed rules around telehealth, liability for overpayment, quality measures, and the Medicare Physician Quality Reporting System. ■Scully’s letter to CMS is posted at http://www.psychiatry.org/advocacy--newsroom/advocacy/9e9023b8-d3da-4c85-a2a2-c02fa8cbad9a. ISSUES NewArchived

Medicare Quality Program Adds Stick to Its Carrot

Medicare Quality Program Adds Stick to Its Carrot

The Coming Value- and Quality-Based Payment Policies

The Coming Value- and Quality-Based Payment Policies

A Pilot Study to Assess the Impact of Structured Diet and Exercise Counseling on Obesity and Quality of Life Measures in South Carolina

Purpose: Obesity is a pervasive problem in the U.S., especially in South Carolina, with 33.9% of the population overweight and 32.6% obese. Obesity is associated with a poor quality of life (QOL), as shown by the Medical Outcomes Study Short Form (SF questionnaires). Medicare and Medicaid proposed intensive counseling for all its patients with a body mass index (BMI) over 30kg/m2 in September 2011. Obesity counseling has been used as a Physician Quality Reporting System measure. This study aimed to assess whether structured counseling on healthy diet and exercise choices in patients with a body mass index (BMI) over 25kg/m2 had an impact on their QOL, understanding the benefits of healthy diet and exercise choices (DAEC) and BMI. Methods: In this prospective pilot study, 104 patients were recruited at a gastroenterology center in South Carolina. At the initial consultation, their QOL and knowledge of DAEC were assessed using the SF-12, and a structured ‘diet and exercise' questionnaire (DAEQ). Their BMI was recorded, and categorized according to the World Health Organisation International Classification of Weight According to BMI (Overweight, Obese class I, II or III). They were counseled for 40 minutes on portion sizes, healthy meal choices and the importance of regular exercise. They were shown how to measure serving sizes. Their comprehension was verified by information recall. Written guidelines were supplied, reinforcing this information. These directives were based on guidance from the American Heart Association and Centre for Nutrition Policy and Promotion. The follow-up period was two months, in which patients received two phone calls to monitor their progress, SF-12 and DAEQ scores, and BMI. Results: Obesity class I patients underwent a significant improvement in mean mental health and DAEQ scores. Obesity class II patients experienced significant improvements in mean BMI and mean physical health scores. There were significant improvements in obesity class III patients' mean BMI and mental health scores. Overweight patients demonstrated improvement in all aspects of the SF-12, DAEQ scores, and reduction in BMI. The results before and after structured counseling are summarized in the ‘Summary of Results' table.Table: Table. Summary of resultsConclusion: This study highlights the benefits of regular counseling, even within a short period, as an intervention for obesity management. With further follow-up, there is potential for greater improvement in results. While these results do not evaluate quality of care due to the outcome measures used, there is an opportunity for physicians to motivate patients in clinics to take responsibility for their own physical and mental health, and to prevent future comorbidities through regular counseling and information reinforcement.

Prostate cancer imaging trends after a nationwide effort to discourage inappropriate prostate cancer imaging.

BackgroundReducing inappropriate use of imaging to stage incident prostate cancer is a challenging problem highlighted recently as a Physician Quality Reporting System quality measure and by the American Society of Clinical Oncology and the American Urological Association in the Choosing Wisely campaign. Since 2000, the National Prostate Cancer Register (NPCR) of Sweden has led an effort to decrease national rates of inappropriate prostate cancer imaging by disseminating utilization data along with the latest imaging guidelines to urologists in Sweden. We sought to determine the temporal and regional effects of this effort on prostate cancer imaging rates.MethodsWe performed a retrospective cohort study among men diagnosed with prostate cancer from the NPCR from 1998 to 2009 (n = 99 879). We analyzed imaging use over time stratified by clinical risk category (low, intermediate, high) and geographic region. Generalized linear models with a logit link were used to test for time trend.ResultsThirty-six percent of men underwent imaging within 6 months of prostate cancer diagnosis. Overall, imaging use decreased over time, particularly in the low-risk category, among whom the imaging rate decreased from 45% to 3% (P < .001), but also in the high-risk category, among whom the rate decreased from 63% to 47% (P < .001). Despite substantial regional variation, all regions experienced clinically and statistically (P < .001) significant decreases in prostate cancer imaging.ConclusionsA Swedish effort to provide data on prostate cancer imaging use and imaging guidelines to clinicians was associated with a reduction in inappropriate imaging over a 10-year period, as well as slightly decreased appropriate imaging in high-risk patients. These results may inform current efforts to promote guideline-concordant imaging in the United States and internationally.

Physician Quality Reporting System: 2013 Update

PQRS : Physician Quality Reporting System The Physician Quality Reporting System (PQRS) is intended to promote the reporting of quality metrics for covered Physician Fee Schedule services provided to Medicare Part B beneficiaries. The program began in 2007 and uses a combination of incentive

Implementing the Physician Quality Reporting System in an Academic Multispecialty Group Practice

The Centers for Medicare and Medicaid Services (CMS) introduced the Physician Quality Reporting System (PQRS) in 2007. PQRS was developed as a value-based, pay-for-reporting initiative intended to increase quality and decrease costs. Jefferson University Physicians (JUP) was an early participant in this voluntary program. In this article, the policy context for CMS's launch of PQRS and JUP's implementation strategy, lessons learned, and an account of benefits and barriers to participation are reviewed. In 2010, JUP achieved 94% provider participation and an average incentive of $772 per participating provider. Net incentives earned across JUP in 2010 topped $171 000, although these earnings were significantly offset by implementation and maintenance costs. PQRS represents CMS's first step toward aligning quality and cost in the ambulatory care setting. Faculty practice plans must be prepared to meet this challenge in order to avoid future penalties and to advance quality of care.

Insights From the Cancer Center Business Summit: Preparing for the Future

We are all aware of the rapid pace at which the delivery of cancer care is changing. Implementation of major provisions of the Affordable Care Act are underway, with the Center for Medicare and Medicaid Services (CMS) issuing multiple regulations that will determine how care is organized, delivered, and compensated. Providers are on a seemingly constant treadmill, scrambling to keep up. There are also important deadlines looming for participation in CMS reporting programs, including the Physician Quality Reporting System (PQRS), meaningful use, and the introduction of the value-based payments. Of course, perennial anxiety over the sustainable growth rate continues. On January 1, 2013, Congress once again stepped in to avoid these cuts by including in the so-called fiscal cliff bill a provision that patched the SGR for one year. One bright note: the legislation required the Administration to establish a process for qualifying clinical registries as a means of complying with PQRS reporting requirements. This opens the door, not only for more meaningful measurement in oncology; it also could allow participants in the ASCO Quality Oncology Program Inititiative (QOPI) to use their work to satisfy PQRS requirements. With unprecedented demands on physician time, how can a busy oncologist hope to stay current with this pace of change? Professional societies like ASCO are a rich source of information that can make a difference. Our education programs and journals are important tools for meeting the challenges ahead. This issue of Journal of Oncology Practice brings together these two vehicles: a collection of articles authored by speakers and panelists who attended the 2012 Cancer Center Business Summit (CCBS). In October 2012, I posted a blog on ASCO Connection describing my experience at the CCBS. I noted that the Summit emphasized the significant challenges facing oncology, but it also left room for hope. Practices are feeling the squeeze of shrinking reimbursement, but they are adapting. Most of us would agree that the future of community cancer care remains uncertain, but, like many others present at the meeting, I left feeling excited about our field and even about the future. Practices are implementing innovative solutions to better coordinate care, contain cost, and become more efficient. Meetings like this are an opportunity for us to share these experiences and to seize opportunity. The CCBS was founded in 2007 and is a sponsor-supported national “think tank” that focuses on best business models and practices for community oncology. The Summit brings together key cancer care stakeholders with business, finance, and legal thought leaders to explore the future course for community oncology in our rapidly evolving health care system. Now in its seventh year, the Summit is recognized as a leading resource for the business of community oncology. It annually conducts a one-and-a-half day conference that includes original research on topics of current interest; a panel on innovative provider initiatives; a panel on payment pilot projects; a Washington update; case studies of strategic options and best business practices; and expert panels on the key business, financial, and regulatory issues facing community cancer care today. The Summit is planned by a national Advisory Board drawn from diverse segments of the community oncology sector. The Summit offers unprecedented education and networking opportunities in the complex world of practice management. Oncology may present some of the biggest challenges in this arena. Recognizing this—and the need it fills for our members—ASCO joined the CCBS as an official sponsor in 2012 and will continue in that role in 2013. This issue of JOP touches on concerns I hear every day from the practicing community: the role of private payers in helping to contain the costs of cancer care; practical issues in palliative care; how payers are collaborating with providers to implement cost-management and delivery models; the oncology medical home and compensation structure within that context; practical details related to moving from private practice to hospital-based practice; effects of the Affordable Care Act's “essential health benefits” on oncology coverage; and an overview of the 340B Program. These are all reports relating to or stemming from the Summit, and they all provide insight I hope will be helpful to you.

Computed tomography scans and cancer risk: Safety efforts

Computed tomography scans and cancer risk: Safety efforts

Eating the Carrot While Dodging the Stick: How to Put Quality Back into Your Quality Improvement Efforts (P18)

1.Discuss the major regulatory, payor, and accreditation requirements for collecting and reporting information on quality that directly impacts hospice and palliative care sustainability and growth.2.Learn about examples of collaborative efforts to collect, share, and act upon information on quality.3.In workshop setting, get expert and peer feedback on your program's current quality improvement efforts, select additional measures to include, get tips on how to move to the next level of impact, and strengthen networks for future collaboration, all in a workshop setting. Payors are increasingly using payment incentives as both a carrot and a stick to speed up meaningful implementation of quality measurement and quality reporting. Impending regulatory requirements for participation in the Centers for Medicare & Medicaid Services Physician Quality Reporting System (PQRS), hospice quality assurance and process improvement, possible future hospice compare, and integration of palliative care domains into hospital and accountable care organization quality reporting requirements are complex, but important to understand. This workshop will help participants: (a) understand the theory that underlies the national quality reporting efforts, (b) use online tools and resources for identifying appropriate standardized quality measures beyond the Fair Employment and Housing Commission, and (c) audit their current process improvement (PI) programs and plan for meeting increasing quality measurement requirements. The workshop will be highly interactive, giving participants the opportunity to collaborate with peers to both give and receive feedback on how to overcome common barriers to implementing transformative and innovative quality improvement programs. Participants will receive a “homework” packet prior to attending the workshop to prepare for conducting an audit of their current PI efforts. Participants will leave the workshop with a plan for implementing standardized national quality measures, reporting the results to program leadership, and using the results to create meaningful change. The workshop will also showcase examples of leading edge efforts to develop better tools for hospice and palliative care quality improvement, such as the Carolina Collaborative. The AAHPM Quality Task Force organizes this workshop, intending that the opportunity for peer-to-peer interaction will seed increased informal collaborations for sharing best PI practices and encouraging the spread of learning organization culture.

Physicians' explanations for apparent gaps in the quality of rheumatology care: Results from the US Medicare Physician Quality Reporting System

The metrics used to assess quality of care and pay for performance in rheumatology are increasingly important. The Centers for Medicare and Medicaid Services established the Physician Quality Reporting System (PQRS) to allow physicians to report performance measures for many conditions, including osteoporosis and rheumatoid arthritis (RA). We described the frequency and nature of physician-reported reasons why recommended care for individual osteoporosis and RA patients was not provided. Using national data on Medicare fee-for-service beneficiaries (2007-2009), we identified health care providers reporting on quality of care for any of 3 osteoporosis or 3 RA measures. PQRS reason codes allowed physicians to submit explanations why recommended care was not given. In 2009, 1,775 physicians reported on ≥1 osteoporosis PQRS measure and 630 physicians reported on ≥1 RA measure. For the older women whose physician reported on lifetime dual x-ray absorptiometry screening at least once since the age of 60 years via PQRS, 76% received such screening. Among the patients with physician-diagnosed osteoporosis reported via PQRS, 82% received prescription osteoporosis medication in the preceding year. For RA medication use reported via PQRS, 89% of patients received a disease-modifying antirheumatic drug or a biologic agent. For the remaining 11-24% of osteoporosis and RA patients, physicians reported medical, patient, system, or other reasons why care was considered but not provided. A substantial fraction of Medicare enrollees who did not receive recommended osteoporosis or RA care had physician-documented reasons for why care was not provided. For Medicare and other health plans that implement penalties for apparent nonperformance or delivery of suboptimal care, it will be important to allow physicians to provide reasons that care was considered medically inappropriate, refused, or otherwise not feasible.

Medicare's Physician Quality Reporting System: Early National Radiologist Experience and Near-Future Performance Projections

The aim of this study was to examine radiologists' experiences during the first 4 years of Medicare's national physician pay-for-performance program and project near-future program outcomes for radiologists. Medicare Physician Quality Reporting System (PQRS) program data from 2007 through 2010 were analyzed, focusing on outcomes and trends for radiologists. Tiered scenario modeling was used to project potential near-future radiologist outcomes as the program transitions from bonuses to penalties. Between 2007 and 2010, PQRS eligible, participating, and incentive-qualifying radiologists increased each year, from 28,899 to 44,026 (+52.3%), 6,237 to 16,770 (+168.9%), and 2,026 to 10,450 (+415.8%), respectively. Mean 2010 incentive bonuses ranged from $2,811.39 for diagnostic radiologists to $12,704.38 for radiation oncologists. Only 23.7% of eligible radiologists (10,450 of 44,026) qualified for incentives in 2010, but this compared favorably with 16.3% for nonradiologists (158,393 of 973,638) (P < .0001) and represented a marked increase from just 2,026 in 2007. Registry reporting more frequently resulted in incentive payments than claims-based reporting (odds ratio, 4.40; 95% confidence interval, 4.03-4.80). Without physician, practice, or program changes, more than 75% of radiologists may face mean penalties of at least $2,654 in 2016, totaling an estimated $111,393,067 for the entire profession. Only a minority of radiologists successfully qualified for incentives under PQRS, but that number has increased each year. Those using registry (rather than claims-based) reporting systems were more likely to receive bonuses. Physician and practice improvements in documentation and reporting, respectively, will be necessary to avert widespread near-future physician penalties.

Use of palliative care measures to support improved patient outcomes and quality of life.

281 Background: Key public-private quality improvement entities, such as the National Quality Forum (NQF) and the National Priorities Partnership, have identified palliative care measures as being critical for the care of cancer patients. In this study, Avalere sought to understand whether current palliative care measures are adequate to support desired patient outcomes, including quality of life. Methods: Avalere conducted searches of large, national quality measure databases—including the Agency for Healthcare Research and Quality’s National Quality Measure Clearinghouse and NQF—as well as public quality measurement programs to better understand the range of existing palliative care measures and the use thereof. In addition, Avalere augmented this research through a review of the white and grey literature to determine how such measures may be better used to support desired outcomes. Results: Several organizations—most notably the American Society of Clinical Oncology (ASCO); the American Medical Association–convened Physician Consortium for Performance Improvement, with the National Comprehensive Cancer Network and ASCO; and the RAND Corporation—have developed measures addressing palliative care for cancer patients. Several of these measures have been subsequently endorsed by NQF. Despite this, few palliative care measures have been incorporated into national quality measurement programs, outside of ASCO’s proprietary Quality Oncology Practice Initiative (QOPI). Conclusions: While it is widely acknowledged that palliative care measures are critical for the care of cancer patients, particularly as it relates to supporting quality of life, little has been done to ensure such measures are incorporated into national public quality improvement initiatives, such as the Centers for Medicare &amp; Medicaid Services’ Physician Quality Reporting System. As calls for increased use of patient-reported outcomes and other palliative care measures continue to rise, policymakers may need to consider incorporating existing, NQF–endorsed measures, such as those used in QOPI, into public programs.

Medicare Changes Some Audiology Codes for 2013

Medicare Changes Some Audiology Codes for 2013

Physician Quality Reporting System Enters Penalty Phase: Practices Urged to Prepare Now to Avoid Medicare Payment Reductions

Oncologists who provide services that are paid under the Medicare Physician Fee Schedule (PFS) are likely familiar with the Physician Quality Reporting System (PQRS). For several years, successful submission of PQRS quality measures to the Centers for Medicare & Medicaid Services (CMS) has resulted in a small bonus payment. More recently, CMS has implemented other reporting programs along with PQRS, including the Electronic Prescribing Program and the EHR [electronic health record] Incentive Program. Uptake of these voluntary CMS programs has been fairly slow across eligible providers in the United States—including oncology providers—reflecting the time and resources required for successful participation. The CMS reporting programs are complex, and the criteria change annually. Consequently, many providers have evaluated the effort required and concluded that it is not worth pursuing the modest bonus. Now, these CMS reporting programs are entering penalty phases, and participation implications should be carefully reconsidered. The first payment adjustment, a 1.5% decrease in PFS payment, will go into effect in 2013 for eligible providers who did not participate in the Electronic Prescribing Incentive Program in 2012. Perhaps more important, decisions regarding 2013 reporting will determine payment reductions in 2014 and 2015. Table 1 summarizes the implications of participation in CMS reporting programs in 2012 and 2013. Table 1. Implications of 2012 and 2013 Participation in CMS Reporting Programs This article reviews eligibility and requirements for the PQRS program. Additional information about PQRS, e-Prescribing, and EHR Incentive programs can be found on the ASCO Web site at www.asco.org/CMSreporting.

Introduction to Value-Based Payment Modifiers

Value-based payment modifiers were legislated by Congress in the 2010 Patient Protection and Affordable Care Act. It is clear in the legislation, and the corresponding proposals published by the secretary of the US Department of Health and Human Services in late 2011, that the intent is to move from paying physicians for reporting to paying physicians for performance. The proposals, developed jointly with CMS, specify that the calculation of payments for performance will be a composite of quality and cost measures. The base year for determining performance benchmarks for the performance measures will be 2013, and the measures will be applied to physician payments on a limited basis beginning in 2015 and to all physician payments by 2017. The role of medical specialty boards, such as the ABR, in the development and deployment of measures is highlighted in this context. CMS's recent conversations with board representatives have indicated their view that the boards' measure development activities are key to increasing physician (especially specialist) participation in the Physician Quality Reporting System to 50% by 2015, from 20% to 30% today. The ABR will continue its past activities in this arena, working with the American Board of Medical Specialties, CMS, and specialty societies, so that ABR diplomates will be able to simultaneously complete their Maintenance of Certification requirements, satisfy the requirements for CMS incentives, and avoid penalties.

2013 Medicare Proposal Outlines New Reporting Rules

2013 Medicare Proposal Outlines New Reporting Rules