It hasn't even started yet, but some physicians are already questioning the long-term sustainability of the CMS' new physician pay-for-reporting program, which may be too burdensome for some practices to implement.
Participating in the program, established by a 2006 tax bill, will require time, resources and staff—something not all physician practices are willing or able to provide, industry experts said. As a result, the physicians who decline to participate in the CMS' Physician Quality Reporting Initiative, or PQRI, will lose out on the 1.5% bonus payment the initiative pays.
Missing out on the PQRI reporting bonus comes at a time when Medicare reimbursements are expected to drop by almost 10% in 2008 or remain the same—an approach that doesn’t account for yearly inflation increases—if Congress intervenes.
And some say the Democratic-majority Congress may decide to limit or trash the program, which was created when the Republicans were in power.
As reimbursement continues to decline and expenses to rise, the CMS is now asking that physicians upgrade and make additional IT investments in their practices to qualify for a small bonus, said Vincent Bufalino, a cardiologist in Naperville, Ill., and a member of the CMS’ Practicing Physicians Advisory Council. Larger practices that already have electronic medical records and see this as an opportunity to jump on the pay-for-performance trend shouldn't have a problem with it, he said. But for those smaller practices with only one or two physicians who are not electronically oriented, "This is going to be a struggle for them," he said.
It's possible that this program could fail because "the majority of practices just do not have the resources," said Sandy Cave, senior practice manager at Fairfax (Va.) Family Practice. "If the practices have the resources to devote they will attempt, if it is not worth the return or the information creates a further/continued 'burden of proof' requiring more documentation, then they would most likely not participate further," she said.
The program would pay the 1.5% bonus to physicians who successfully report on 74 measures on claims for dates of services from July 1 to Dec. 31.
But Congress may decide to interrupt the CMS' plans and take the program in an entirely new direction, said Patrick Smith, senior vice president of government affairs at the Medical Group Management Association.
The tax extender bill that created the PQRI was written by a Republican majority, he said. Under the new Democratic leadership, Rep. Pete Stark (D-Calif.), who chairs the House Ways and Means health subcommittee, or some other lawmaker may decide to write a different law that could revamp the PQRI. It's likely this could take place as Congress takes up legislation to correct the 10% cut Medicare physicians are expected to receive in 2008, he said. Stark's office was unavailable for comment.
The 2008 rulemaking is expected to be proposed by Aug. 15, with an implementation date of Nov. 15. Yet, the funding for the PQRI in 2008 has yet to be appropriated, and some physicians wonder if the program will last another year. "I can't speak with certainty" about what Congress is going to do about the PQRI, said Thomas Valuck, director of the CMS' Special Program Office of Value-Based Purchasing, during the advisory council meeting.
The bonus payment won't come quickly either, since the calculations on the claims data won't be completed until February, said Jennifer Miller, external relationship liaison at the MGMA's government affairs department. Physician practices already had difficulties with the PQRI's predecessor, the Physician Voluntary Reporting Program.
"Most likely, there will be similar challenges to reporting under the new program," she said.
Moreover, questions remain on how ready the agency is to administer the program. Bufalino said the CMS is still working on the program's implementation, which could delay feedback to physicians.
But Valuck challenged the notion that the CMS—and smaller practices—weren't ready for the program. "All system changes have been made, and we're fully ready to implement the PQRI on July 1," he said in an interview.
In his experience, the smaller practices seem more flexible than the larger ones and should not have a problem adapting to what is a simple claims-based quality reporting process.
Overall, this is a worthwhile venture for all practices, not just because of the financial incentive, but because practices will be getting quality improvement information from the CMS to improve their performance and will be making an investment in the future of their practice, he said.
However, even those practices that have an electronic medical-records system may have to invest in additional resources to submit the claims data. Cave said her practice was working with an outside physician to extract the data, rather than spend $50,000 on additional software. Another challenge is figuring out which measures are the easier or most "digestable," so that the practice will able to report the data with accuracy, Cave said.
Bufalino acknowledged that his practice has had an EMR system for 10 years and it still took several months to modify the system to get it ready to submit the claims data that the agency is requiring of practices.
The criticisms come at a time when the CMS is gearing up to enact new measures in 2008. Unlike the original 74 measures, the 2008 set will be established through a rulemaking process, a decision announced last week. "Congress told us in the statute to implement the existing measures, plus any additional measures that could be developed by a consensus process in time for implementation for the 2007 PQRI. Then for 2008, we were to develop measures through rulemaking," said a CMS spokeswoman.
Next year's measures will include structural measures such as the use of electronic health records or electronic prescribing technology, said Michael Rapp, director of quality measurement and the health assessment group with the CMS' Office of Clinical Standards and Quality, during a meeting of the Practicing Physicians Advisory Council last week. The measures must also be adopted or endorsed by a consensus organization such as the AQA alliance or National Quality Forum, he said.
Bufalino said that having a rulemaking and comment period will help build consensus by allowing all of the specialty societies to weigh in on the measures. "But the one thing we don't need is another set of 50 measures," he added. Instead, "we need to tweak the ones we already have."
This story initially appeared in this week's edition of Modern Healthcare
magazine.
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