Sunday, May 3, 2015

PQRS: Medicare, Payments, Penalties

As we had indicated five to six years ago in this set of analyses, the ACA will be placing an unending set of costs and tasks upon physicians. PQRS is another example soon to hit the street.

 The details of PQRS are:

The Physician Quality Reporting System (PQRS) is a quality reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare. PQRS gives participating EPs and group practices the opportunity to assess the quality of care they provide to their patients, helping to ensure that patients get the right care at the right time. By reporting on PQRS quality measures, individual EPs and group practices can also quantify how often they are meeting a particular quality metric. Beginning in 2015, the program will apply a negative payment adjustment to individual EPs and PQRS group practices who did not satisfactorily report data on quality measures for Medicare Part B Physician Fee Schedule (MPFS) covered professional services in 2013. Those who report satisfactorily for the 2015 program year will avoid the 2017 PQRS negative payment adjustment.

A summary for this program is on the CMS Site. Basically PQRS requires that CMR reimbursed physicians collect and report what they call "Quality" statistics. For example with Type 2 Diabetes the Quality metric would be:

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.

Frankly what that metric has to do with quality care one really wonders. If one is treating patients who are morbidly obese, say in a minority community, and you have tried everything up to an including insulin and the patients do nothing to try to do anything then why is this a quality metric? It is meaningless. You can tell a morbidly obese patient to reduce their weight but for many it is a hopeless task. Do physicians now get penalized for not doing what?

The enabling law for PQRS is stated as follows:

Affordable Care Act.  The Affordable Care Act makes a number of changes to the Physician Quality Reporting System, including authorizing incentive payments through 2014 and requiring a penalty, beginning in 2015, for eligible professionals who do not satisfactorily report. The Affordable Care Act also authorizes an additional 0.5 percent incentive for 2011 through 2014 for eligible professionals who satisfactorily report and more frequently than is required to qualify for or maintain board certification status participates in a Maintenance of Certification Program for a year and successfully completes a qualified Maintenance of Certification Program practice assessment for such year.

 This PQRS adds a tremendous reporting burden on the physician. Now they have EHR to do, billing, PQRS, and for what? Who will read all of this. Then there is compliance. What if one makes a mistake, audits can start and penalties apply. 

The key question is what benefit to the patients results from this process. It is not at all clear to anyone at this stage. It just drives up costs and impairs care. That is not quality!