PQRI Report Card: Failing Grades for CMS

Citing frustrations and broken promises, ophthalmologists give the program low marks

BY RENÉ LUTHE, SENIOR ASSOCIATE EDITOR

Empowering patients to choose high-quality healthcare providers is surely a noble goal, and it was with such aspirations in mind that CMS launched Medicare's Physician Quality Reporting Initiative (PQRI) in 2007. The program asked for voluntary reporting of quality-of-care data to CMS, and in turn the agency would note which practices participate; patients who cared to research their physicians would get some small measure of assurance that they met basic minimum requirements of care.

On the surface, PQRI seemed like a reasonable, positive program. Doctors who participate would be compensated for their time with a bonus of up to 1.5% of their Medicare allowable charges incurred during the reporting period. The bonus amount would be gradually reduced, then phased out entirely in 2015, when PQRI would become mandatory and practices that did not participate would be fined. What could go wrong?

Quite a lot, as many ophthalmologists have attested. Many feel that in its short existence, PQRI offers fresh support for one of President Ronald Reagan's most famous statements: "The nine most terrifying words in the English language are, ‘I'm from the government and I'm here to help.’" In assessing PQRI's early efforts, a program with the impertinence to give report cards to physicians has gotten one in return, and the marks do not impress. Here's an examination of PQRI's problems and possible solutions.

The Collective Outcry

Because PQRI has so quickly achieved notoriety, many ophthalmologists are already familiar with its shortcomings. If you've participated in the program and found it lacking, you are not alone. Here's a sampling of common difficulties reported by physicians.

One of the major irritants, according to Cynthia Mattox, MD, of Boston's New England Eye Center, is that participants don't get real-time updates as to how their data are being received by CMS, "so you can't double check to be sure that you're qualifying." Additionally, the reports CMS provides come out in the summer or fall of the following year. "By the time you get your graded reports and see if you qualified, it's too late to even make corrections for the year that you're already involved with," Dr. Mattox explains. "You get the report for 2008 in the middle of 2009 and in the meantime you've already been doing the same process in 2009 that you were doing in 2008. If you were doing it incorrectly, you didn't know better."

Jamie Zucker, MD, in private practice in Canton, Ohio, conveyed his frustration with the absence of feedback from CMS. "You have no idea if you're doing it right or wrong, then a year and a half goes by, and you get no money," he says. "There's no one to call, there's no liaison, there's no feedback along the way."

Indeed, at press time, the phone numbers listed on the PQRI Web page were simply for CMS — there was no phone number dedicated to PQRI queries.

Dr. Zucker attempted to apply what he had learned from his first year's CMS report to reporting for the third year of participation, but he says that he wouldn't be surprised if the practice still didn't receive any reimbursement. He says that he has tried seeking guidance from the Academy and CLAO, but can get no clear answers as to what he has done incorrectly.

"No one can look at our data and say, ‘This is what you're doing wrong; make this correction and it will all be fine.’ It's very frustrating to have spent all this time and not have received a penny in reimbursement," Dr. Zucker says.

The reports he received from CMS for his previous two years of participation in PQRI didn't afford much enlightenment. "They throw the numbers at you and the documents basically just say, ‘You didn't report the right amount of measures,’ or ‘The percentage of the correct measures are not enough.’" There is no accompanying instruction as to how to correct the error, Dr. Zucker says. One report he received was 20 pages of meaningless numbers. "It lists ‘Measures eligible reporting’ and it's either 0 or 1. I assume the 0 means they didn't get the report and the 1 means that they did, and that's it. Obviously we didn't get much out of the report, because we did it wrong the next year too, or at least we didn't get paid."

"We felt like it was a very straightforward thing," says Anthony P. Johnson, MD, in private practice in Greenville, SC, of PQRI when his practice decided to participate. Based on his practice's size, he estimated that the bonus payment on their Medicare billings would be approximately $35,000 to $45,000.

But problems began immediately. "It was a nightmare from the get-go," says practice administrator Linda Dahlgren. For starters, the PQRI Web site was onerous to navigate, Ms. Dahlgren says. "We're all used to living by Web sites these days, but this one was poor." Getting through the site's security and locating passwords took up two days.

Though the practice eventually received some reimbursement, it was much lower than they had anticipated: only $8,672 in total, Ms. Dahlgren says. The piecemeal manner in which some smaller subsequent reimbursements arrived only added to the confusion. "These checks came with no notation as to the participating doctor."

The physician report cards from CMS were another source of frustration. Dr. Johnson's group of ophthalmologists had eight eligible measures, and the optometrist in the practice had six. Ms. Dahlgren reports that based on the summary of the reporting feedback, most physicians reported all eight measures that ophthalmologists were required to report. Two of the providers, she says, were not required to report on the full eight measures because of their subspecialty in glaucoma or retina. "However, on the feedback report, our doctors were held responsible for up to 19 measures, 11 more than appropriate and an outright error for the requirement of ophthalmologists," Ms. Dahlgren says.

"On my report card," Dr. Johnson remarks, "it said that I didn't report bone density appropriately, and other things that were just out of bounds" for an ophthalmologist. "It was comical."

Furthermore, Ms. Dahlgren says that the practice's internal data revealed that they had submitted more reporting instances than were credited. "This ranges anywhere from 10% to 15% more reporting submitted than the ones for which we were credited."

Proof in Numbers

Physician unhappiness with PQRI is not merely anecdotal. The Medical Group Management Association (MGMA) released results of a study in which medical practice leaders cited multiple, continued administrative challenges with reporting data for PQRI.

Their research indicates that of responding practices that attempted to participate in the 2008 PQRI, fewer than half (48%) were able to successfully access their 2008 PQRI feedback report, a slight decline from the 51% that were able to retrieve their 2007 PQRI feedback report. Further, the majority (60%) of practices that accessed their 2008 feedback reports were either somewhat dissatisfied or very dissatisfied with the report's presentation of the information.

An even larger majority (67%) was somewhat or very dissatisfied with the 2008 PQRI report's effectiveness in providing guidance to improve patient care outcomes. Compared with the approximately five hours it took to access their 2007 PQRI feedback reports, on average it collectively took almost nine hours by all practice staff and physicians to download the 2008 PQRI reports.

As for scoring the clarity of the feedback report, while the numbers of dissatisfied or very dissatisfied improved in 2008 from the 59.2% recorded in 2007, the majority of the 2008 respondents still fell into those categories — 55.1%.

MGMA has called on Congress and CMS to establish what it says is "a much-needed PQRI appeals process" and for the agency to be given needed resources so that it can provide participating providers with interim feedback.

Identifying the Errors

William Rich, MD, medical policy director for the American Academy of Ophthalmology, concedes that up until this year, the PQRI experience has "been very, very difficult, because it's complex." Approximately 57% to 58% of all ophthalmologists tried to report on PQRI, he states, but of that number, less than 50% successfully completed the process. His own practice, he says, did not complete PQRI successfully the first year, though they learned from their mistakes and managed to get a bonus payment the second year they participated.

In addition to the whole reporting process, the inability of practices to learn from CMS what they might have done incorrectly that prevented them from receiving bonuses, or did not receive bonuses commensurate with their submissions, is an issue of significant aggravation for participants.

"It's easier to find out how to make a dirty bomb than to get your report card from CMS," Dr. Rich says dryly. "Not getting paid is one thing, the doctors say, but not understanding why they weren't paid, and the impediments to finding out why, that's really aggravating to docs."

The Academy's own research identified billing errors that prevented successful PQRI reporting in 2007 and 2008. Here are some of tips that it says could have helped many ophthalmology practices receive an incentive bonus:

► Add the Category II codes to the appropriate ICD 9 diagnosis on the superbill or encounter form, or create a cheat sheet for physicians and staff that includes the measure information.
► Select more than three measures, if possible. This gives you a buffer in the event you fail on one measure.
► Put one cent in the charges section of CMS 1500 form. It could be the practice system or the payer system doesn't accept a zero charge.
► Submit the Category II code on the same page of the CMS 1500 form as the corresponding CPT_code/HCPCS code.
► The exam or surgical CPT code should be followed by the PQRI measure(s). Any other tests or procedures should follow the PQRI measure(s).
► Check your EOMB to assure the Category II code(s) is present with the corresponding exam or surgical code.
► Note all covered diagnosis codes for each measure, not just those with which you are most familiar.

For a complete list of reasons, go to www.aao.org/pqri.

Reasons that incentive payments were not made, the Academy found, included problems with the National Provider Identification number, corresponding diagnosis codes that were not linked to exam or surgical codes correctly, and human error in neglecting to report the Category II and/or HCPCS code (see sidebar below for a complete list).

Dr. Mattox suggests that part of the reason so many practices have been unsuccessful is that they had to meet the criteria for reporting 80% of the time for the PQRI codes. "And 80% of the time is a pretty high standard," she say. "If you missed claims for even two or three months, which happened in our practice, you were in danger of not meeting the 80% criteria — even if you did it 100% of the time perfectly when the claims were going through well."

It's a Front Office Problem

That's the contention of some. In other words, according to the Academy's and CMS's findings, the errors originated in the practice.

"Almost all the reasons for lack of successful reporting occurred from the time the physician checked off the box — selected the proper code that they did perform the measure on that patient — to the time the person at the front desk took that and entered it into a billing form and forwarded it to someone who collates the data and sends it to CMS," notes Dr. Rich.

Dr. Mattox agrees. The front-desk staff, billing staff and the physician all needed to be educated as to the proper information to record on the patient encounter form or EMR system. "There were a lot of steps to follow through on."

The solution, Dr. Rich says, is better staff training. "Some of the people at the front desk are overworked but, frankly, they never followed the guidelines that were put in place by the administrators and the docs." He also points out that practices tend to see more turnover in front-desk staff, further complicating adherence to the reporting system. Dr. Rich believes staff will continue making the same errors that have bedeviled PQRI reporting efforts in previous years until practice leaders make clear to their administrators what steps need to be followed, and make periodic checks to verify that staff is following those instructions.

Potential Solutions

For those who have had it with the claims-based approach to PQRI reporting, Dr. Rich says that other alternatives are available. In an effort to keep physicians from becoming so demoralized that they give up on PQRI, the AAO and the American Society of Cataract and Refractive Surgeons have investigated another way members can report for 2010, called registry reporting. The Academy has negotiated an agreement with a company called Outcome, a group that creates data registries and performs outcomes research.

Dr. Mattox explains the way registry reporting works: practices that have signed up with Outcome report their data in batches, perhaps at the end of the year or another designated point convenient for the practice, then the group reviews your data for accuracy and sends it on to CMS. "Apparently, other specialties that have been using this registry type of process to do their PQRI have had a much higher percentage of practices that are successful in the reporting," she says.

According to Dr. Rich, registry reporting shows a success rate of more than 95%. Moreover, practices that utilize electronic billing can export much of the data required from the billing system directly into the registry. "Ophthalmologists can go to the Academy's Web site (www.aao.org/pqri) if they're frustrated with the administrative claims reporting and do it by registry," Dr. Rich says. There is a yearly fee of $595 per physician, which includes submission of the data to CMS. It's "a good return on investment," he observes. Physicians contract with Outcome independently.

For those who started 2010 with the claims-based system, Dr. Mattox says it's permissible to switch to registry reporting in the same year. "Once you switch to the registry, CMS will ignore the claims-based, supposedly, and just take your registry information." You'd have to retrospectively submit your previous claims data for the year via the registry.

Another change for 2010 PQRI reporting, Dr. Mattox says, is that there are two reporting periods for the year: Jan. 1 through Dec. 31 for the 2% bonus on the entire year's allowables, and July 1 through Dec. 31 for the bonus on six months of allowables, so practices that were not ready to participate at the typically busy start of the new year still have a chance to participate and obtain payment.

Given that a fee is involved with registry reporting, will the doctor still come out ahead financially if the practice choses this method? Dr. Rich believes most physicians will very quickly see a return on their investment. "All you have to do is the math," he explains. "Suppose you have $400,000 in Medicare billings. Ten percent would be $40,000; dividing by five would give you 2% — that's $8,000. Thus, you have a return on investment of $5,000 vs. $595 for the fee. So it does make economic sense to do the registry."

There's another potential solution for the PQRI reporting mess, though the Academy is still in the process of developing it. Composite measures, according to Dr. Rich, would constitute a much simpler method than claims-based reporting. He offers an example of how it would work: "For a cataract patient, there are about three or four things that are individual PQRI measures. If they get approved as a composite measure, you would report on all four. All you would have to do is submit 30 patients and you get your bonus."

While the composite measures are still being developed by the Academy, Dr. Rich believes they will be much more thorough gauges of treatment. "I think that's where the future is going to be: composite measures that include outcomes and patient-reported experience," he says.

But How Will it Play in Peoria?

Perhaps gun-shy after their formative experiences with PQRI reporting, some practices are wary of the proposed solutions. On the topic of guidelines for claims-based reporting, for instance, Dr. Zucker points out that while the Academy can offer general guidelines to getting the process right, "They can't get into your own data and see where the problem is. We all have different computers, different clearinghouses."

Additionally, the guidelines offered do not, in his view, take into account the possibility that the errors may be on CMS's end of the transaction. "It may be that the mistakes occur between your computer and the clearinghouse, or between the clearinghouse and CMS — you don't know."

As for the necessity of better staff training, Ms. Dahlgren feels that may have to begin with CMS. "They gave us the measures to go by, but I don't remember very specific instructions to begin with," she says. "I don't think you can train if you don't have a good set of guidelines to go by."

These practices also see potential problems with registry reporting. The fee for Outcome may not be worthwhile if a practitioner has only slight involvement with Medicare. "As a pediatric ophthalmologist and having limited Medicare age-group involvement, I would never generate the reimbursements to break even," Dr. Johnson says.

Another potential problem when using an intermediary, Dr. Johnson points out, is that the practice would have to somehow monitor the registry service to ensure that it was giving CMS the correct data.

And although the fee involved in contracting with a registry service might lead one to expect greater convenience for the practice, Dr. Zucker notes that this doesn't appear to be the case. "The person assigned to the PQRI reporting may even require more time with the registry system because she has to enter into a second file, or registry file."

Finally, after paying the fees and devoting any additional time that registry reporting requires, Dr. Zucker says it appears at this point to require a "leap of faith" to believe the practice will obtain the PQRI bonus money it should. "My practice has five doctors, so we could spend $3,000 to get nothing," hw worries. "Three grand, plus my staffer's time, maybe to get zero out of it. I'm not thrilled at the prospect of doing this." Still, he says he may enroll if his practice can get some sort of guarantee that it will indeed obtain the bonuses.

Dr. Johnson is equally reluctant about trying a registry method. "It seems like something is wrong if you are having to employ somebody else to do this right," he says.

PQR… Why?

Still, PQRI proponents note that there are two very good reasons to give reporting another try: (1) The financial reward for those who do the process correctly, and (2) PQRI reporting will be the law of the land in 2015, when participation will no longer be voluntary or eligible for financial reward.

"There's still quite a bit of bonus money out there to get," Dr. Mattox points out.

Dr. Rich concurs. Ophthalmology receives the largest percentage of Medicare revenue, so the 2% bonus of Medicare billings is a significant amount.

And it is an opportunity that not all medical specialties have. Dr. Mattox says that many subspecialties did not get their measures approved with CMS in time. "They aren't even eligible to get the bonus. At least we had the opportunity to do it if we chose to."

Clinicians should keep in mind that the bonuses gradually decline until 2015 — and cease altogether that year, when the reporting will become mandatory and CMS will impose penalties of up to 2% per year of your Medicare billings for not participating. "You might as well get the money upfront" while it's available, Dr. Rich suggests. "It is a done deal and is in the new health care bill."

Asked if she were concerned that her practice might be penalized if it doesn't enroll in PQRI in the future, Ms. Dahlgren answered, "We are concerned about participating. Gathering data is important, but the process needs to be simplified." OM