Reform Update: Doc groups concerned over looming Medicare penalties tied to quality reporting

Medicare will begin docking physicians' pay next year if they decline to report on quality measures under a voluntary system launched in 2007. Providers, however, remain confused and frustrated by its framework.

The program—the Physician Quality Reporting System, or PQRS—will gain even more significance in 2017, when the CMS will apply a value-based modifier to physician payments based on the quality data collected.

Physicians had little time to analyze their 2013 data to help choose their best option for PQRS reporting for the next 12 months, which the Medical Group Management Association, a trade group for physician practices, says is typical of its frustrations with the program. The CMS allows providers to report the data as individuals or groups, and there are several avenues for reporting, including Medicare Part B claims, qualified clinical registries and electronic health records.

Medical groups seeking to participate in the 2014 PQRS' group practice reporting option must register by Sept. 30, yet those who participated in the 2013 program received notice last week if they qualified for incentive payments.

If physicians met PQRS quality-measure reporting criteria in 2009 and 2010, they received a 2% bonus of their Medicare Part B charges. This percentage fell to 1% for 2011 and to 0.5% for 2011 through 2014. This year's financial incentive was also reduced by 2% under the broad federal budget cuts known as sequestration.

“The decreased incentive being offered is not that significant. The greater concern is on the penalty going forward,” said Anders Gilberg, the MGMA's senior vice president for government affairs. For 2015, failing to participate could mean a 2% penalty.

The PQRS requirements for 2015 will not be known until the release of the final 2015 Medicare physician fee schedule in November, so the recently received feedback received for 2013 performance has limited usefulness, Gilberg said.

“It's not the most actionable information,” Gilberg said. “It's also resulting in a level of provider frustration that's as high as it's ever been.”

A chief concern for the MGMA has been the subtle differences and redundant reporting of the same data for PQRS, the CMS value-based payment modifier, and the incentive program for the meaningful use of electronic health records.

When all of these programs move from awarding bonuses to issuing penalties, doctors could face a cumulative 11% reduction in Medicare payments, by the association's tally.

Current plans, as mandated by the Patient Protection and Affordable Care Act, call for applying the value-based payment modifier, or VBPM, to Medicare payments in 2017 based on 2015 PQRS data.

The current state of provider thinking on PQRS could be summed up in one word: “confusion,” said Melissa Blom, an account executive with Covisint, a company offering Web-based applications for PQRS participation.

Blom said the same cycle of data release and registration requirements happened last year, so medical groups should have been prepared. She added that the 2013 data—if released earlier—could have been used to help validate physician decisions to either report individually or as a group.

“While it could have made a difference for some, they should have already have had an idea of what they might do,” Blom said.

Some groups have discussed not participating in PQRS and just accepting whatever penalties are assessed, but Blom said that is short-sighted and often based on an incorrect assumption that the program won't continue.

“Not only is it not going away, there will be more penalties and awards based on their ability to demonstrate they've delivered high-quality care at low cost,” she said. “If they don't participate, the hit is going to be a lot more than they realize, and I think they will regret it.”

The Indiana State Medical Association, Indiana Hospital Association, AARP Indiana and other organizations joined together last week for an orchestrated push to get the CMS to approve Gov. Mike Pence's latest iteration of his Healthy Indiana Plan, also known as HIP 2.0.

Pence submitted his plan to the HHS in July. His supporters note how the program would “replace traditional Medicaid,” and how HIP 2.0 would empower participants to take charge of their health—this would include making monthly payments of $3 to $25 for an increased level of coverage.

“Under HIP, inappropriate emergency room usage decreased, while the use of preventive care increased across the entire HIP population—for physicians, that's good medicine,” Dr. William Mohr, a past-president of the Indiana State Medical Association said in a statement to the media. “We can anticipate that HIP 2.0 will be even more effective in the future and that improved rates for the HIP population will continue to increase participation by physicians.”

The plan also includes an increase in physician Medicaid reimbursement up to 75% of Medicare levels paid, in part, by cigarette taxes.

Follow Andis Robeznieks on Twitter: @MHARobeznieks