Seizing the “Pay-For Performance” Carrot

Federal incentives to adopt PQRS, EMR and e-Rx are luring physicians to a more efficient future. Are they within your reach?

By René Luthe, Senior Associate Editor

PQRS, e-Prescribing, EMR implementation incentives—these are the latest programs from the federal government that have been frustrating physicians. While the government has dangled pay-for-performance program bonuses—the promise of up to 1.5% of the physician's Medicare allowable charges, just for documenting their treatments using the latest information technology—before them, the reality has been that all too often, doctors find that those bonuses remain tantalizingly out of reach.

Implementing these programs into the real-life practice of medicine has not been easy. Many ophthalmologists have been frustrated by the absence of detailed instructions, the late-coming and vague reports, the frequent failure to win those bonus dollars—and sometimes just the notion of Uncle Sam poking his nose into how they practice medicine. As Larry Patterson, MD, of Crossville, Tenn., says, “It is the federal government: bloated, out of control and unaccountable!”

It's enough to make many ophthalmologists want to give up, or not even bother to try. But they can't. The reality is that the disappointment of not winning bonus dollars will soon be followed by something worse, as the penalties for not participating kick in over the next few years. The lack of adoption of EHR, e-Prescribing, PQRS and maintenance of certification amounts to four penalties that are additive once we reach 2017, notes William Rich, MD, medical policy director for the American Academy of Ophthalmology. “The difference in revenue for the profession is between about $220 million, the first year of these things, to about $350-$400 million in penalties down the road,” Dr. Rich says. For an individual practice, the swing could be as much as 11% of revenue of the course of the various programs. (see Table 1, below).

Can ophthalmologists learn to finesse the system before the federal carrot turns into a stick? Those in the pay-for-performance trenches say “yes.” Here's a look at where things stand.

PQRS Problems and Successes

Begun in 2007 as the Physician Quality Reporting Initiative and now called PQRS (for Physician Quality Reporting System), the program requested voluntary reporting of quality-of-care data to CMS, which would note the practices that participate; patients who researched their physicians would get some small measure of assurance that they met basic minimum requirements of care, and participating doctors 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 PQRS would become mandatory and practices that did not participate would be fined.

Yet four years in, the most common complaint about this straightforward-sounding program remains the same: You don't learn if your submissions are accurately formatted for one year until you are a good two-thirds of the way through the next year. If you're submitting the same way in the current year as you did the previous one, you learn you've been perpetuating those same mistakes when it's almost too late to submit enough measures accurately and win bonus dollars for that year. “We can't do this correctly if CMS isn't going to give us feedback,” says Dr. Patterson.

This leads to another common complaint about the program: reimbursement, if it comes, takes a long time. Most practices could probably use that money sooner rather than later. And if you weren't successful, of course, you put a lot of manpower into participation and got nothing.

Dr. Rich concedes that communicating with CMS about the program “is still a mess.” While the situation has improved, he believes the concerns with security continue to make it very difficult. “I'm not an idiot, but I couldn't find my own report,” he says. “It's still so bureaucratic because the legal beagles mandated so many security measures that I think it would probably be easier to get a bomb onto a plane than it is to get your reports,” he jokes.

Still, he maintains, his practice managed to learn and improve. The first year he participated, Dr. Rich did not qualify for a bonus. The second year, however, he obtained approximately $15,000 in bonuses between PQRS and e-Prescribing. “There are 10 doctors in my group and we all got bonuses, so that's wonderful.”

Few would dispute that, but Dr. Patterson maintains that PQRS and the other programs still have a critical, damning flaw: “I have no evidence that a single patient in America has gotten better care because of this.”

Despite the problems with the early stages of implementation, Dr. Rich points out that the ophthalmology field on the whole did pretty well with PQRS, as well as with e-Prescribing.

In PQRS, ophthalmology finished third in overall dollars and successful submissions. Thirty-nine percent of ophthalmologists participated or tried, he reports, and of that number, 50% were successful. The average bonus was $7,266. In e-Prescribing, 30% of ophthalmologists participated, and 70% were successful.

Though the numbers of ophthalmologists participating in either program seems low, Dr. Rich cautions that the AAO does not yet know how many ophthalmologists were simply ineligible due to an absence of Medicare patients. Pathologists and pediatric ophthalmologists, he notes, would not have qualified. He also anticipates that more ophthalmologists will enroll in the pay-for-performance programs once there is more prevalent adoption of EMR systems, which simplify data collection and submission.

Maybe. But with numbers like these, should ophthalmologists believe their next attempt would bring them anything besides aggravation?

The Good News

There's reason to believe it would. Here are the specific improvements those participating in PQRS will find.

• For starters, the lines of communication with CMS for the program are much better. There's now a helpline for participating physicians who have questions, called QualityNet Helpline (call 866-288-8912, or you can also go online to www.qualitynet.org/pqri). Anecdotal data suggests that the service lives up to its title. Donna McCune, of Corcoran Consulting Group, attests that she has referred clients. “People say they have been able to get responses,” she says.
• Additionally, there are now documents on the CMS Web site (www.cms.gov/pqrs) that walk practices through the process of PQRS submission. Ms. McCune says they are well designed.
• Also in contrast to last year, there is an explanation of benefits that comes with payment (assuming payment comes). The remittance advice lists the codes on the claims, so practices can see if they have been transmitted. While checking this is fairly simple for a small practice, it will be a more time- and labor-intensive endeavor for larger practices.
• Another major help to participating physicians is that CMS has reduced requirements for the measures submitted. Whereas an 80% accuracy rate was required through 2010, it is now only 50%. “So obviously the government realizes that people who are submitting claim by claim are struggling,” says Ms. McCune.
• When it comes to sending out bonuses, CMS seems to be working some of the kinks out of the program's system. According to Priscilla Arnold, MD, who practices in Bettendorf, Iowa, payments for 2010 appear to be making their way to physicians a little faster than in previous years. “While the payment for the work done in 2010 is still not speedy, that process was completed earlier this year than previous years.”
• An improvement that is not quite here yet, but is in the hopper, Dr. Rich assures, is additional, relevant measures to accommodate specialists. While the high-volume diseases such as diabetes and glaucoma are covered, he concedes that there have not been sufficient measures for subspecialties including oculoplastics, pediatrics and immunology.

But he points out that to have measures, an evidence base is first required. “You have to show that there are gaps in care and that if you do these procedures, you can narrow those gaps,” he explains. “It's not that you just make this up, these things are all validated” by peer-reviewed evidence. Toward that end, a committee is working on developing measures for subspecialties that currently lack much of an evidence base. “It's very laborious to get that, and the regulatory process to get them approved is fairly strenuous too, but we'll get it done,” Dr. Rich says.

The Registries Alternative

While communication on how to implement PQRS is improving, some may not want to count on receiving clear and prompt explanations from the federal government to save their bonuses, or to save them from penalties in the future. Ophthalmic societies are trying to help physicians better control the process themselves by offering another option. AAO and ASCRS are jointly promoting a registry, called Outcomes. For approximately $600 per physician, the CMS-approved registry will submit your data to PQRS—completely and correctly. According to Dr. Rich, registry reporting shows an 88% success rate—significantly higher than that of office-based claims.

“You are not dependent upon the correct billing, coding and submission by your front office staff, which is the biggest problem, by the way: lack of compliance,” Dr. Rich explains.

Registries submit only once for the entire year, Ms. McCune notes, so they can look for incomplete information, whereas “if a practice misses a particular patient, they can't go back and refile the claim.” A registry, however, can continue to accumulate the data until they are sure that they have everything at the end of the year. Then they submit the information. Thus, practices have until Jan. 31, 2012 to submit their 2011 data. Ms. McCune calls the decision to go with a registry “a slam-dunk if they will ensure that you get 2% of your total Medicare-allowed dollars.”

Outcomes provides online explanations and training to demonstrate how registry reporting works.

Still, a registry will not make all of the headaches associated with PQRS disappear; the practice must still input the required data. It's a significant deterrent to some doctors. “We're going to have to pay money to a registry, but we've still got to do all the work,” points out Dr. Patterson.

While AAO coding executive Sue Vicchrilli, COT, OCS, concedes that registries do require staff involvement, she notes that practice management software can make the process less onerous. “Some systems can automatically speak to PQRS registries; others, you have to enter the data into their field screens.”

Each practice will need to perform a cost-benefit analysis in deciding whether to enroll with a registry, says Ms. Vicchrilli. Simply figure out what 1% of the practice's Medicare Part B, Railroad Medicare and Medicare as a secondary payer allowables are, and subtract the costs of joining the registry and the calculated staff time, says Ms. Vicchrilli. If financially sound, joining the registry is an excellent alternative to claims-based reporting. Practices may also report e-Prescribing at no additional costs.

So far, Dr. Rich reports that only approximately 500 Academy members have enrolled in the new program. However, he believes the looming deadlines for the penalties associated with opting out of the various pay-for-performance programs will cause many physicians to embrace registry reporting. Enrollment should “skyrocket by 2015, probably, because of the stimulus and penalties for EMR adoption,” Dr. Rich believes.

Beware Changing Deadlines

“Doing the math” may lead some to conclude that it isn't yet in their interest to participate in PQRS and put it off for as long as they can—in this case, they believe, until 2015. “There are still practices that have made the decision that they don't feel the time, money and effort required are worthwhile,” notes Dr. Arnold. This view could be increasingly prevalent as bonuses continue to decline. Yet non-participating practices may be faced with penalties sooner than they think.

Ms. McCune reports that in July's proposed fee schedule for 2012, CMS will use data from 2013 to decide which physicians to penalize in 2015. “My interpretation of that is that if you're not playing in 2013, you will be penalized in 2015, whether you are playing or not,” she says.

She notes that the deadline for e-Prescribing was moved as well, when CMS announced that practices that were not participating this year, or were not submitting a sufficient number of claims between January and June of this year, would be penalized in 2012, whether they were participating in 2012 or not. “They claim it takes them that long to analyze the data,” she explains.

So while a proposed deadline change for PQRS is still just a proposal, Ms. McCune says that she is advising clients to consider participating in the program by 2013.

Moreover, Dr. Rich reminds, these penalties will hurt. They will become much more onerous around 2015, he says. “You will lose between 5.5 to 7% of your Medicare payments per year as far as you can see. There is no limit to the losses, so that could just wipe you out.”

Consider the Fringe Benefits

Dr. Rich points out that the use of registries offers ophthalmology, and medicine in general, some impressive gains besides winning PQRS bonus dollars.

■ Better outcomes. Most significant, Dr. Rich says, is that they dramatically improve outcomes by providing physicians a “dashboard” to gauge the efficacy of their treatments. They offer immediate feedback on patterns of care and surgical results. “It's like having this monstrous, live, real-time listserv, with data flowing back and forth between you and your peers.” Further, many registries offer decision support on the best practices for clinical care. Cardiology, Dr. Rich notes, has five registries. “They actually had every single heart surgeon in the United States looking at their own dashboard—outcomes for different procedures: bypass operations, valve replacements, etc.” The ophthalmology profession, he feels, is rather behind other specialties in adopting them.

■ Drug/device tracking. Registries also offer quick, effective postmarket surveillance of both drugs and devices. He notes that it took years to accumulate the data demonstrating the link between NSAIDs and cardiac deaths. Registries, however, can pick up on factors that do not appear to be related and provide instant feedback. Total hip replacements performed in the United States offer a perfect example of registry's efficacy, Dr. Rich says. “Here, they track every single hip that's done so that they can say, ‘this device stinks,' rather than it's being reported three or four years later. The result is that subpar devices are weeded out much sooner.”

■ Improving licensure, education. Maintenance of certification for physicians' licensure is yet another task that registries make smoother. They also can be used to send education modules back and forth for more rapid learning, Dr. Rich says.

Registries work, Dr. Rich explains, through a device that is similar to a cable box for a television. It extracts data elements from a practice's computer system, regardless of EMR system used, and feeds the information into its registry. “You don't have to sit there and plug it all into a computer,” says Dr. Rich. “It's an amazing advance.”

As for E-Prescribing…

By comparison with PQRS, e-Prescribing—the program rewarding adoption of an electronic prescribing system that transmits prescriptions ordered by the provider to a desired pharmacy—has been much more successful: ophthalmology had a 30% participation rate in 2009, and a 71% success rate at obtaining bonuses, making it one of the most successful of all the specialties, Ms. Vicchrilli reports. It helps that participation is a much more straightforward process, without the headaches of PQRS. According to Ms. Vicchrilli, software, some of which is free, is just about all a physician needs. “You just have to make sure you submit G8553, and then you watch your remittance advice to verify that it was accepted.”

Ms. McCune agrees that the program's relative simplicity has helped make it a success. “Ophthalmologists and optometrists embraced the e-Prescribing bonus program right from the get-go, because they saw bonus money and they saw that was not too difficult to achieve,” she says.

Moreover, e-Prescribing thus far is turning out to be what practices especially love: a prompt payer. CMS began sending out bonus checks for the program in August, with the expectation that they would be completed by month's end. Dr. Patterson is one of the happy recipients. “It was actually for the amount that it was supposed to be,” he says. “It was a tremendous experience! The bonus helped pay for the e-Rx software company we used to be able to do it.”

While penalties for non-participation began this year for 2012 payments, CMS has also made it easier for physicians to avoid them. In order to duck that penalty next year, Ms. Vicchrilli explains, physicians who do not qualify for an exception or apply for an exemption had to report 10 out of the total required 25 times from their offices (rather than through a registry) between Jan. 1 and June 30. After that, the submission of another 15 for a total of 25 is required in order to avoid the penalty in 2013. “If you didn't e-Prescribe 10 times between Jan. 1 and June 30 of this year, you will get 1% less in 2012. If you prescribe 25 of them, however, by the end of the year, you will get a 1% bonus,” Ms. Vicchrilli says. “So you break even and you will avoid the penalty in 2013.” (For more information on the exceptions and exemptions, visit www.aao.org/e-rx.)

Dr. Arnold notes that though CMS did lower the requirements for e-Prescribing since its launch in order to make participation easier, there has been no decrease in the costs for implementation.

Here to Stay

While there's reason to believe that attempts at pay-for-performance programs will more likely yield rewards now, there is no reason to believe the programs will go away. The desire to ignore them, and the additional work they require, in the hopes that they will disappear is understandable, but Dr. Arnold feels strongly that it would be unwise to do so. She believes it is crucial that practices learn which programs work best for them and to participate. “I do not believe that some form of quality measurement is going to disappear.”

In fact, Dr. Arnold believes more stringent outcomes measures are more likely in the future. Toward that end, ophthalmic organizations such as ASCRS and AAO are providing their members with a number of resources to educate them about the programs and help them succeed with them—newsletters, Webinars and the annual meetings all feature detailed information (ascrs.org, aao.org). “CMS has made it very clear that their long-term intention is to find a way to differentiate physician payment, or to stratify physician payment, at least in part, based on what they consider quality measurement,” Dr. Arnold says. “It's very important for practices to be involved with that.” Especially while they can still reap bonuses from doing so. OM