Healthcare Business News

Specialists notch victory in new CMS rule on quality reporting

By Andis Robeznieks
Posted: December 4, 2013 - 12:30 pm ET

Medicare has agreed to allow specialist medical societies to determine the quality measures physicians will report when the new reporting system goes into effect on Jan. 1.

The rule represents a major victory for the specialty societies, which had protested a common set of quality measures that many said favored primary care and family physicians over specialists. CMS in 2015 will begin imposing penalties on physicians who fail to report to one of these new "qualified clinical directories," which will satisfy requirements for participating in the agency's Physician Quality Reporting System.

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Dr. Arthur Lerner, with Palm City, Fla.-based Technology Education Consulting in Healthcare, said the new rule creates more incentive for specialists to participate in PQRS and opportunities for them “to take control of the process”—a process that he said is currently geared toward only primary-care doctors.

“It's an exercise that has no meaning,” said Lerner, former executive vice president of the American Society of Breast Surgeons. “PQRS hasn't been, at least in my opinion, anywhere near as successful as the CMS hoped it would have been.”

The new rule is contained in the 2014 Medicare physician fee schedule. Congress called for it in last year's last-minute fiscal-cliff budget bailout, known as the American Taxpayer Relief Act of 2012.

The fee schedule reported that 26,515 medical practices with 266,521 eligible professionals participated in PQRS in 2011—or about 27% of those who were eligible. The CMS paid out almost $262 million in PQRS incentives for the 2011 program year, with the average payment being $1,059, or about 0.5% of a physician's Medicare Part B charges. The CMS estimates that 400,000 professionals are expected to participate in 2014. Starting in 2015, physicians who don't participate will be hit with a 1.5% penalty based on their 2013 part B charges.

Lerner said many specialists are prepared to take the hit or, as the CMS calls it, the “adjustment,” rather than waste their time with PQRS. He noted that there are no PQRS measures related to breast surgery, and the existing surgical measures lean toward inpatient operations rather than outpatient procedures.

Jennifer Gasperini, senior government affairs representative for the Medical Group Management Association, said she is still studying the rule but thinks, because of its complexity, it may not boost participation as much as the CMS would like.

The regulations define qualified clinical data registries as a CMS-approved entity that “collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients.” A qualified clinical data registry must be in operation a year before submitting data to the CMS, provide feedback to participants at least four times a year and possess benchmark capability. The registry must have at least 50 clinical participants (down from the originally proposed figure of 100), and it can't be managed by a single, locally owned specialty group.

Not all registry participants need to participate in PQRS, and data can be submitted from all payers—not just Medicare.

Other requirements include providing evidence supporting each measure, maintaining a data privacy and security plan, and submitting an acceptable data validation strategy. For 2014, physicians would need to submit data on nine quality measures that cover at least three National Quality Strategy domains and that at least one measure deal with patient outcomes.

“Our members would support anything that makes their lives easier, and I don't know if this program does that,” Gasperini said. “It mimics the existing PQRS criteria very closely and looks almost identical to me.”

She added that it may benefit physicians who are already participating in a clinical registry and are already submitting data similar to what the CMS is asking.

Lerner, whose consulting business helps in the development of registries, was more optimistic.

“The rule change empowers societies, medical boards and healthcare organizations to create data registries for their members that would include their own CMS-approved quality measures,” he said in a news release. “This would more closely address the quality of patient care that their members provide.”

There may also be an inherent conflict, as medical societies may be steered toward developing quality measures that put their members in a positive light rather than creating measures that would automatically rank 50% of them in the bottom of their fields.

Lerner didn't think this would happen as specialist society-developed measures would still require CMS approval.

“When a new measure is submitted for consideration, there must be a rationale for wanting the measure, including any data to support the measure,” he said. “CMS will not simply accept any measure submitted, so it is highly unlikely that a self-serving measure would be approved.”

Tom Granatir, senior vice president for health policy and external relations for the American Board of Medical Specialties, agreed.

“Look at the registries that have been in existence in Europe and the U.S.,” Granatir said. “They've led to great improvements.”

Granatir cited the Society of Thoracic Surgeons' database, which was launched in 1989. “It's been incredibly successful in standardizing care,” he said.

Other registries have greatly improved care for cystic fibrosis and rheumatism, he said, adding that several more specialty society registries are in the works.

Follow Andis Robeznieks on Twitter: @MHARobeznieks

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