Physicians Practice - September 2008 - (Page 32) PUBLIC POLICY dates down our throats. They are totally out of sync with the reality. It is likely to be an ugly fight.” “PQRI is a flagrant effort to get doctors to unknowingly enroll our patients into a huge medical experiment without their consent or even their knowledge.” “PQRI is idiotic and adds nothing to quality of care…” Unhinged conspiracy theorists? Hardly. After all, most pay-for-performance programs define performance according to patient outcomes, as if you have total control over patient behavior. But there is only so much you can do to get a diabetic’s blood sugar or weight under control. It’s up to them to stay out of the McDonald’s drive-thru. “Now more than ever we can look at these quality measures,” says Schreiber. “There’s been an explosion of data reporting but costs are going though the roof. More reporting has coincided with more costs.” Although PQRI is, for now, merely a voluntary pay-for-reporting program — if you choose to participate, you could get paid bonuses for reporting on your performance of various tests and screens — its detractors worry that it will inevitably become a mandatory penalty for nonperformance-of-yourpatients program: If they don’t get healthier, you get paid less. Indeed, CMS itself seems to be feeding this speculation. In announcing the first-year payouts on July 15, acting administrator Kerry Weems called them a “first step toward improving how Medicare pays for health care services.” Weems did not elaborate on what the next step would be, but added: “We all can agree that the current payment system needs to be reformed to pay for high quality care rather than continuing to pay for volume of services. The PQRI has proven to be a successful step towards establishing a value-based purchasing program for physicians.” But certainly not everyone would agree with Weems’ characterization of PQRI as a proven success when barely more than half of its participants 32 | PHYSICIANS PRACTICE | SEPTEMBER 2008 correctly followed the rules, according to the program’s own creators. Schreiber says that PQRI’s deciders “don’t listen to the people in the trenches.” And most doctors dislike the whole concept of outcome-based medicine. “Nothing’s going to change,” Schreiber says. “Unless you want us to discharge our noncompliant patients. Then we’ll see some change.” There are other, more objective, concerns regarding the mechanics of PQRI, as well. Just as the Sacajawea dollar confounded soda machines, PQRI reporting can foul up your claims processing. PQRI requires reporters to add the information onto the practice’s regular Medicare claim. But there is no money in the “amount” box for the PQRI line item, and this baffles PARTICIPANT BEWARE Medicare’s Physician Quality Reporting Initiative (PQRI) can be a tricky road to trek. Here are a few FAQs to smooth the way. Q Will I have to modify my billing system? A Possibly. You’ll be reporting PQRI claims through your billing system, right along with regular claims to Medicare. This poses a potential problem, because the PQRI claim has no money associated with it — you’re simply reporting that you performed a specific measure — which can cause the billing software to automatically reject the claim. Discuss your intent to participate in the PQRI program with your billing software vendor, your outsourced billing company, and/or the clearinghouse you use. They may have to make some changes to make sure the PQRI claims process correctly. This could cost you some money. Q Do I have to have an EMR to participate? Also, some measures are a bit dicey, such as “High Blood Pressure Control in Type 1 or 2 Diabetes Mellitus,” where you must remember to report both the systolic and diastolic numbers. Q Why would I choose more than three measures? A The best reason to choose more than the required three is that it gives you some leeway in case you have reporting errors. CMS regulations state that if you report on four or more quality measures applicable to your specialty, then at least three of them must be reported for at least 80 percent of reportable cases. This gives you a little safety net. Q What started all of this anyway? A It’s part of the Tax Relief and Health Care Act of 2006. Q Where can I read up on the PQRI participation rules? A CMS has a boatload of Web pages devoted to PQRI, found at www.cms.hhs.gov/pqri. This route can be rather daunting, as wading through all of them can be overwhelming. However, the Tip Sheet and Fact Sheet do hold some useful and comprehendible information. Consider checking out CMS’ newsletter, “MLN Matters.” Or, tap into the resources of the Medical Group Management Association at www.mgma.org (you’ll want their government affairs office) or your own professional society. The American Society of Hematology’s Web site (www.hematology.org), for one, has a very informative Q&A on PQRI. Click “Policy,” “Resources for Practitioners,” and “Physician Quality Reporting Initiative (PQRI).” WWW.PHYSICIANSPRACTICE.COM A No. You could use a paper system, such as the one used by internist Ron Hirsch (see main article, page 28), but you’ll need to be very organized so information doesn’t get lost or separated from the main claim. Note that although an EMR could make the whole process easier, you might have to spend time tweaking it to do so, when a paper system could work just as well. Q How do I decide which measures to report on? A That depends a lot on your specialty, but, in general, it’s best to select codes that are the least tied to patient compliance to make the reporting as easy, successful, and straightforward as possible. CMS encourages practices to report on all measures applicable to their specialties, but this could get very unwieldy, especially for primary-care practices. http://www.cms.hhs.gov/pqri http://www.mgma.org http://www.hematology.org http://WWW.PHYSICIANSPRACTICE.COM
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