This is the second in a two-part series summarizing the highlights of the Proposed Medicare Physician Fee Schedule Rule for calendar year 2011 and recent legislative updates, which together will help shape the structure of the 2011 Medicare Physician Fee Schedule.

PHYSICIAN QUALITY REPORTING INITIATIVE
The Physician Quality Reporting Initiative (PQRI) is a voluntary reporting program that was implemented by CMS in 2007. Through the PQRI program, an eligible provider (EP) that successfully reports specified quality measures may be eligible for an incentive payment. There is no requirement for EPs to sign up or register with CMS for participation in the PQRI. However, EPs participating through a qualified registry or EHR may have to meet certain registration requirements specific to the particular reporting mechanism.

Some of the most significant changes to the PQRI are enacted through the Patient Protection and Affordable Care Act known as the Affordable Care Act (ACA) which together with the Health Care and Education Reconciliation Act (HCERA) forms the comprehensive health care reform bill.

INCENTIVE PAYMENTS & PENALTIES
The ACA authorizes PQRI incentive payments through 2014 and imposes penalties, beginning in 2015, for eligible professionals who do not satisfactorily report.

Eligible professionals who successfully report PQRI measures in 2011 will qualify to earn an incentive payment of 1.0 percent of their total estimated allowed charges for Medicare Part B Physician Fee Schedule (PFS) covered professional services ( this does not include drugs or labs) furnished during that same period. For 2012 through 2014, successful reporters may earn an incentive payment of 0.5 percent.

Beginning in 2015, eligible professionals who do not successfully report PQRI measures may be subject to a payment adjustment or penalty. In 2015, the penalty for not successfully reporting is 1.5 percent, this penalty rises to 2.0 percent for 2016 and each subsequent year.

Additional Incentive Payment     
Furthermore, the ACA allows for an additional 0.5 percent incentive for 2011-2014 for eligible professionals who meet the following requirements:

• Satisfactorily submits data on quality measures under PQRI for a year through a Maintenance of Certification Program (MOCP), operated by a specialty body of the American Board of Medical Specialties (ABMS) meeting the criteria for a registry under PQRI, or in an alternative form and manner determined appropriate by the Secretary;
• Submits the data more frequently than is required to qualify for or maintain board certification status;
• Participates in such an MOCP for a year; and
• Successfully completes a qualified MOCP for such year.

The ACA defines a MOCP as a continuous assessment program, such as a qualified ABMS MOCP, or an equivalent program (as determined by the Secretary), that advances quality and the lifelong learning and self-assessment of board certified specialty physicians by focusing on the competencies of patient care, medical knowledge, practice-based learning, interpersonal and communications skills and professionalism.

MOCPs must require a physician to:

• Maintain a valid, unrestricted medical license in the United States;
• Participate in educational and self-assessment programs that require an assessment of what was learned;
• Demonstrate, through a formalized, secure examination, that the physician has the fundamental diagnostic skills, medical knowledge, and clinical judgment to provide quality care in their respective specialty; and
• Successfully complete a qualified MOCP practice assessment.

Under the ACA, a qualified MOCP practice assessment is an assessment of a physician’s practice that includes:

• An initial assessment of an EP’s practice that is designed to demonstrate the physician’s use of evidence-based medicine;
• A survey of patient experience with care; and
• The requirement that a physician implement a quality improvement intervention to address a practice weakness identified in the initial assessment and then to re-measure to assess performance after such intervention.

In addition, to qualify for the additional incentive payment, the MOCP Program is to submit the following information to CMS on behalf of the EP:

• That the EP has successfully completed a qualified MOCP practice assessment for such year;
• If requested by the Secretary, information on the survey of patient experience with care; and
• As the Secretary may require, on the methods, measures, and data used under the MOCP and the qualified MOCP practice assessment.

In the 2011 proposed rule, CMS addresses the ACA’s additional PQRI incentive payment and proposes to require the following:

• To be eligible for the additional 0.5 percent incentive payment, EPs must satisfactorily report for a 12-month reporting period rather than only a 6-month reporting period. EPs may report as an individual using individual PQRI measures or measures groups and submitting the data via claims, a registry or group practice reporting option (GPRO), or through a qualified MOCP. 
• The EP must have data submitted on his/her behalf through an MOCP, for the MOCP in which the EP participates. The MOCP, although not required to become a qualified registry for PQRI submission, must meet the criteria for a registry for submission of the MOCP data.
• Participation and successful completion in at least one MOCP practice assessment. Those physicians whose specialty board requires them to participate in an MOCP to maintain board certification status would need to complete the MOCP practice assessment one additional time to qualify for the 0.5 percent incentive payment.
• EPs who do not have available, through their boards or otherwise, an MOCP practice assessment would not be eligible for the 0.5 percent incentive payment.

Organizations that want to participate as an MOCP and enable their members to be eligible for the additional PQRI incentive program will need to go through a self-nomination process by January 31, 2011. MOCPs will also need to provide to CMS signed documentation from the EP that the EP wants to have their information released to CMS.

Other CMS proposals for the 2011 PQRI include the proposed PQRI reporting mechanisms, the proposed criteria for satisfactory reporting, the proposed measures and measures groups, creating an informal appeals process, providing timely feedback reports to EPs and establishing the new Physician Compare website.

REPORTING MECHANISMS
CMS is proposing to retain the 2010 PQRI reporting methods and reporting periods for individual EPs for calendar year 2011.  Individual physicians using claims-based or registry-based reporting will have the option of 6-month and 12-month reporting periods. In addition, CMS proposes to retain the 12-month reporting period for the group practice reporting option (GPRO), initially introduced in 2010, and the EHR-based reporting option whereby a limited subset of the proposed 2011 PQRI quality measures may be reported through a qualifying EHR.

While proposing to retain the claims-based reporting option in 2011, CMS states their intention to phase-out or significantly limit this PQRI reporting option after 2011 thus allowing CMS and EPs to devote available resources towards maximizing the potential of registries and EHRs for quality measurement reporting.

In particular, CMS identifies the following limitations inherent with claims-based reporting:

• Quality measures requiring multiple diagnosis codes are not as conducive to claims-based reporting and may be associated with a greater number of invalidly reported quality data codes (QDCs);
• When multiple measures share the same codes it may be difficult to determine which measure(s) the EP intended to report through claims;
• Only half of the EPs participating in PQRI through claims-based reporting satisfied the criteria for satisfactory reporting and qualified for the incentive payment;
• Claims cannot be resubmitted for the sole purpose of adding QDCs so claims-based reporting must be concurrent with billing.

CMS points out the problems associated with reporting QDCs through claims-based reporting, a system developed for billing purposes, are not an issue when QDCs are reported through registries. Furthermore, in contrast to the low rate of success for claims-based reporting, over 90% of EPs using the registry-based option in the 2008 PQRI qualified for the incentive plan. CMS reports the number of qualified registries has increased since 2008 and they expect additional registries to become qualified in future years.

PROPOSED CRITERIA FOR SATISFACTORY REPORTING

Reporting of Individual Quality Measures for Individual EPs
CMS is proposing to reduce the reporting requirements for claims-based reporting of individual measures in an effort to encourage broader participation in the PQRI program and increase the rate of EPs qualifying for the incentive program.

In previous years, EPs reporting individual quality measures through claims-based reporting were required to meet a threshold of reporting at least three measures (or one or two measures if less than three measures are applicable to the services of the provider) in at least 80% of the cases in which the measures apply. In the proposed rule, CMS notes that a major reason for the low success rate of claims-based reporting was the failure of the EP to report at the required 80% threshold. Therefore, CMS proposes lowering the reporting threshold for claims-based reporting of individual measures to 50% in 2011.

CMS is not proposing to lower the reporting threshold for EPs reporting individual measures through qualified registries or EHRs, EPs reporting through these mechanisms must report on at least three measures for at least 80% of the FFS patients receiving services where the measure applies.

PROPOSED 2011 CRITERIA FOR REPORTING ON INDIVIDUAL QUALITY MEASURES

Claims-Based Reporting – 6 or 12-Month Reporting Period:

• Report at least 3 PQRI measures, or 1-2 measures if less than 3 measures apply to the EP; and
• Report each measure for at least 50% of the EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.

Registry-Based Reporting – 6 or 12-Month Reporting Period:

• Report at least 3 PQRI measures; and
• Report each measure for at least 80% of the EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.

EHR-Based Reporting – 12-Month Reporting Period:

• Report at least 3 PQRI measures; and
• Report each measure for at least 80% of the EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.

Reporting of Measures Groups for Individual EPs
Individual EPs will again have the option to report measures groups, through claims or registries, instead of individual quality measures to qualify for the PQRI incentive payment. CMS proposes to retain the 2010 reporting criteria for measures groups with the exception of the reduction of the reporting threshold from 80% in 2010 to 50% in 2011.  Once more, CMS states the purpose of the reduction in the reporting threshold is to increase the successful reporting rate for participating EPs.

PROPOSED 2011 CRITERIA FOR REPORTING ON MEASURES GROUPS

Option #1 - Claims-Based Reporting 12-Month Reporting Period

• Report at least 1 measures group; and
• Report each measures group for at least 30 Medicare FFS patients.

Option #2 – Claims-Based Reporting 12-Month Reporting Period

• Report at least 1 measures group; and
• Report each measure group for at least 50% of patients seen during the reporting period to whom the measures group applies; and
• Report each measures group on at least 15 unique Medicare Part B FFS patients seen during the reporting period to which the measures group applies.

Option #3 – Claims-Based Reporting 6-Month Reporting Period

• Report at least 1 measures group; and
• Report each measure group for at least 50% of patients seen during the reporting period to whom the measures group applies; and
• Report each measures group on at least 8 unique Medicare Part B FFS patients seen during the reporting period to which the measures group applies.

Option #4 – Registry-Based Reporting 12-Month Reporting Period

• Report at least 1 measures group; and
• Report each measures group for at least 30 Medicare FFS patients.

Option #5 - Registry-Based Reporting 12-Month Reporting Period

• Report at least 1 measures group; and
• Report each measure for at least 80% of patients seen during the reporting period to whom the measures group applies; and
• Report each measures group on at least 15 unique Medicare Part B FFS patients seen during the reporting period to which the measures group applies.

Option #6 – Registry-Based Reporting 6-Month Reporting Period

• Report at least 1 measures group; and
• Report each measure for at least 80% of patients seen during the reporting period to whom the measures group applies; and
• Report each measures group on at least 8 unique Medicare Part B FFS patients seen during the reporting period to which the measures group applies.

Established in 2010, the Group Practice Reporting Option (GPRO) allows for group practices of 200 or more practitioners to participate in the 2010 PQRI as a group with the incentive payment provided to the group rather than the individual. CMS is proposing to continue the GPRO I option, for group practices of 200 or more practitioners, in 2011 and to include a new group reporting option, GPRO II, for group practices with 2 to 199 practitioners.

PROPOSED MEASURES & MEASURES GROUPS
For 2011, CMS is proposing to retain the vast majority of the 2010 PQRI measures. The proposed rule includes tables of the proposed measures in four measures categories:

• Table 52: Claims-based and registry-based reporting measures
• Table 53: Registry-based reporting measures only
• Table 54: New individual measures
• Table 55: EHR-based reporting measures

According to CMS all 2011 quality measures and measure specifications including instructions for reporting and identifying the circumstances in which each measure is applicable will be published on their website no later than December 31, 2010.

PQRI INFORMAL APPEALS PROCESS
CMS proposes to meet the ACA requirement of an informal PQRI appeals process based on their current inquiry process.  Under the proposed appeals process, an EP must request an informal review in writing within 90 days of the release of his or her feedback report. CMS will provide a written response within 60 days and if found that the EP did satisfactorily report, CMS will provide the applicable incentive payment.

FEEDBACK REPORTS
CMS proposes to meet the ACA requirement for timely feedback reports by continuing to provide feedback reports on or about the time of issuance of the incentive payments. In addition, CMS proposes to provide interim feedback reports to EPs reporting 2011 measures groups under the claims-based reporting mechanism. Because EPs reporting measures groups may choose to report on 30 eligible cases, rather than a certain percentage of eligible cases, these interim feedback reports would allow an EP to know how many more cases must be reported to meet the alternate reporting criteria.

STAKEHOLDER COMMENTS
In comments to CMS on the 2011 PQRI proposals, the American Society of Clinical Oncology (ASCO) states their support for the use of registry-based reporting as the primary mechanism for reporting PQRI data. ASCO also urges CMS to integrate their Quality Oncology Initiative Program (QOPI) within the PQRI program stating that QOPI, a data-driven quality improvement program with over 600 registered community-based oncology practices across the country, is the obvious vehicle to promote the use of quality programs in oncology including participation in PQRI.

ASCO contrasts the lack of meaningful oncology performance measures in the PQRI with the current 84 clinically relevant performance measures in the QOPI program and expresses their willingness to work with CMS staff on the PQRI.

PHYSICIAN COMPARE

CMS is required by the ACA to establish a Physician Compare web site by January 1, 2011. The website is to include information about physicians enrolled in the Medicare program and providers who participate in the PQRI. In 2011, CMS proposes to post information on EPs and groups who successfully participate in PQRI, CMS will not post EP or group performance information for the 2011 PQRI.

Starting January 1, 2013 CMS has to implement a plan for making information on physician performance public on the Physician Compare Web Site. The ACA requires that the measures for public reporting of physician performance include, to the extent practicable, the following:

• Measures collected under the Physician Quality Reporting System;
• An assessment of patient health outcomes and the functional status of patients;
• An assessment of the continuity and coordination of care and care transitions, including episodes of care and risk-adjusted resource use;
• An assessment of efficiency;
• An assessment of patient experience and patient, caregiver, and family engagement;
• An assessment of the safety, effectiveness, and timeliness of care; and
• Other information as determined appropriate by the Secretary.

With regard to the Physician Compare web site, the ACA requires the assurance of patient privacy, input from multi-stakeholder groups, and taking into consideration the plan to transition to value-based purchasing. The ACA also authorizes CMS to establish a demonstration program by January 1, 2019, to provide financial incentives to Medicare beneficiaries who are furnished services by high quality physicians.

CONSULTATION SERVICES

In the 2010 final rule, CMS eliminated the payment for consultation codes (with the exception of telemedicine consultation codes) effective for dates of service on and after January 1, 2010. Providers were instructed instead to report either a new patient visit code or established patient visit code for office/outpatient services, or an initial hospital care visit or subsequent hospital care visit for inpatient services.

In determining to eliminate the consultation codes, CMS cited the desire to reduce confusion and the administrative burdens associated with filing these services and their belief that that no specialties would see their revenues decline by more than 3% due to the change. 

In April 2010, 17 specialty societies participated in the AMA’s survey of Medicare’s elimination of consultation codes. Out of 7,781 respondents, about 5,500 completed most of the questions.  The results of the AMA survey, shown below, illustrate that revenue losses are considerably higher than that predicted by CMS.

A June 18, 2010, letter sent to CMS by the AMA and thirty-three specialty societies, calls for CMS to review and revise their policy of eliminated consultation codes to avoid further financial losses to practices leading to the reduction of services provided to Medicare patients and the subsequent deterioration of coordination of care for these patients.

In the 2011 proposed rule, CMS solicits comments on the perspectives of physicians and nonphysician practitioners caring for Medicare beneficiaries under the current PFS policy since the elimination of payment for consultation services.

STAKEHOLDER COMMENTS
In their comments, the AMA provides specific findings from their survey and calls for CMS to reverse its current policy of and resume payment for consultation codes. According to the AMA, the survey suggests that continuation of the current policy will lead to additional cutbacks in care making it impossible for many specialists to purchase electronic medical records systems and adopt new technologies that are the cornerstone of transformation for healthcare reform in the ACA.

ASCO also urges CMS to reverse its current policy and resume payment for consultation codes under Medicare. ASCO reports that the elimination of consultation codes has resulted in an inequitable situation for oncologists and other sub-specialists who must frequently consult with patients with complex medical histories.

According to ASCO, the redistribution of value from the eliminated consultation codes to the new and established patient E/M services is unfair and inequitable, resulting in decreases in payments to oncologists in excess of 25% for these services.  ASCO voices their concern that the policy is adversely impacting access to care.