“To Err is Human,” published by the Institute of Medicine in 1999, set off a firestorm of quality initiatives when it announced that at least 44,000 to 98,000 people die in hospitals every year because of medical errors. The first quality initiatives, which were aimed at hospitals, have now trickled down to physician practices. For two years there have been reports of payors moving to a pay-for-performance system or value-based purchasing.
This past December, Congress passed the 2006 Tax Relief and Healthcare Act. One component of the legislation was the Physician Quality Reporting Initiative (PQRI), which will pay physicians a bonus for reporting quality measures along with Medicare claims. The program provides a 1.5% lump-sum payment based on the quality of patient care rather than the quantity or nature of services rendered. (See “Medicare Quality Movement Reaches Clinicians,” June 2007, p. 1 for more information on PQRI.) PQRI is one example of actions taken by payors in recent years to hold providers more accountable for the care they give and to tie it directly to compensation. This trend could alter the way Medicare payments are calculated, so physicians should join the quality movement early.
Quality and Medicare Reimbursement
Congress and the CMS are struggling with the flawed Medicare Physician Fee Schedule and providing appropriate reimbursement to physicians (see “ACR Unites with AMA to Fix SGR,” p. 10). The Balanced Budget Act of 1997 enacted the SGR that was originally intended to control the growth in Medicare physician spending. The Medicare Payment Advisory Commission (MedPAC, also established by the Act) advises Congress on the Medicare program and offers testimony about the SGR and the Medicare program. In March 2007, MedPAC reported that, “the SGR is widely considered to be flawed; it neither rewards physicians who restrain volume growth nor punishes those who prescribe unnecessary services.”1 Congress and the CMS now realize that the SGR needs to be fixed. The current fee schedule is based on the quantity of resources consumed rather than quality or value. CMS has asserted that it is on a path to “transform Medicare from being a passive payer to an active purchaser” through value-based purchasing programs like PQRI. According to the CMS, the goal of PQRI is to “encourage higher quality and avoid unnecessary costs to enhance the value of care.”
The ACR Government Affairs Department continues to stress that a new formula must be enacted without further short-term fixes. A new formula must be created, but what will it cost? Many suggested alternate formulas have large price tags and pay practitioners regardless of the quality of the service. Medicare spending has increased by 9.3% while the gross domestic product only increased 6.5% between 1980 and 2004. A recent MedPAC report stated that, “despite this rapid growth in spending, a large body of evidence suggests the increased cost of healthcare has not come with a corresponding increase in quality.”2 MedPAC has included recommendations to Congress that relate to quality, efficiency, health information technology, and physician payment reform.
Pressure to move toward value-based purchasing and away from fee-for-service healthcare has also surfaced from outside CMS in recent years. President George W. Bush has repeatedly spoken in support of the idea. He issued an Executive Order in August 2006 requiring transparency in quality measurement and pricing, national standards for health information technology, and programs that promote quality and efficiency. In addition, he has included allowances for quality-related programs in his past three annual budgets. In the private sector, health plans and employer coalitions like Bridges to Excellence have established pay-for-performance or pay-for-reporting programs. Several payors have established physician ranking systems to allow patients to choose a physician based on their “star ranking.”
ACR Approach to Quality
The quality movement is well underway, and PQRI is but one facet of it. In the midst of such a changing environment, what should the ACR do?
Some advocate that, on principle, the ACR and its members should refuse to be involved in any program that measures physician performance. Yet ACR members are ultimately responsible for delivering high-quality patient care. If members indeed provide such care, then there is no reason to object to being held accountable for it. Others suggest that the ACR and its members take no action and wait for the current quality “trend” to pass. Yet evidence suggests that healthcare providers will be required to participate in some form of quality measurement in the near future, if they are not already involved.
Still others recommend that the ACR get involved in the quality process and influence it from within. The ACR has chosen this path. Its goal is to become increasingly involved in the current quality movement so that the ACR and its members have as much input as possible into the systems by which rheumatologists and rheumatology health professionals will be evaluated. The ACR believes that physicians and health professionals should only be evaluated against evidence-based measures developed by rheumatology professionals. Additionally, reporting data for quality measurements should be rewarded with financial incentives meaningful enough to encourage providers to participate. PQRI uses evidence-based measures, some of which were developed in collaboration with the ACR. It also provides financial compensation for participation, albeit minimal; the ACR will continue to advocate for increased payment for those who participate in the program.
Why Get Involved?
ACR members have much to gain by getting involved in PQRI—especially at this early stage. First, participants will receive confidential feedback to support quality improvement in their practices. (This information will not be made publicly available.) Second, participants may earn bonus incentive payments for meeting quality-reporting requirements. Finally, participants will be making an investment in the future of their practices. It is expected that higher bonus incentives will be offered in the future, pay-for-performance programs in the private sector will become more numerous, and public reporting of performance results will become standard practice. ACR members who prepare now will be in a better position later.
Join the Quality Movement
To get involved with PQRI:
- Visit the ACR Web site (www.rheumatology.org/practice/qmc/pqri.asp) and the CMS PQRI Web site (www.cms.hhs.gov/PQRI) for additional information on PQRI. Note in particular the Educational Resources page of the CMS PQRI Web site;
- Explain PQRI to your staff and educate them on the importance of reporting the quality measures; and
- Create new superbills that include quality-reporting codes to assist your office staff.
Your office processes and systems must be able to accommodate PQRI to be successful both now and in the future. Establishing a quality structure will make it easier to meet measurement and reporting goals. The July 1 start date has already passed, but practices can still participate in PQRI.
The ACR encourages its members to participate in PQRI this year—and to get started as soon as possible. Every day you wait after July 1 will make it more difficult to meet the minimum requirements for the July 1–December 31, 2007, reporting period. Meanwhile, the ACR will continue to work on behalf of its members to ensure that the measures used by CMS and others are reasonable and that members have the information and tools they need to succeed.
References
- Testimony: Assessing Alternatives to the Sustainable Growth Rate System. March 6, 2007.
- Testimony: Improving Medicare Efficiency and Value. April 18, 2007.