Physician Quality Reporting Initiative (PQRI)

Memo to: Physicians
From: Michael D. Maves, MD, MBA, Executive Vice President, CEO, AMA
Date: October 22, 2008
Subject: Physician Quality Reporting Initiative (PQRI)

According to the Centers for Medicare and Medicaid Services (CMS) data, approximately 16 percent of physicians and eligible professionals participated in the 2007 program, but nearly 50 percent of participants did not receive any bonus payment. In an effort to help inform the American Medical Association’s (AMA) advocacy efforts with Congress and CMS regarding how to improve the PQRI, AMA conducted a survey in September to assess experience with the 2007 PQRI. To be eligible for the survey, one must have participated in the 2007 PQRI. Four hundred and eight surveys (408) were completed.

Summary of PORI Survey Results

• Many respondents found participating in the 2007 PQRI program difficult. Sixty-one percent of total respondents rate the program moderately, considerably, or extremely difficult.
• Regarding whether a practice earned a bonus payment for their participation in the 2007 program, 40 percent said yes, 29 percent said no, and 31 percent did not know.
• Regarding the amount of payment: 34 percent received $10,000 or more; 26 percent received $2,501–$10,000; 16 percent received $1,001–$2,500; 13 percent received $600–$1,000; and 11 percent received less than $600.
• According to CMS, the average bonus payment amount for individual 2007 PQRI participants is over $600, and an average bonus payment for physician group practices is over $4,700.
• Only 22 percent of respondents successfully downloaded the PQRI Feedback Report for their practice. Of those who downloaded the report, less than half found it instructive.
• Fifty-seven percent of respondents found accessing the 2007 PQRI Feedback Report from the CMS website to be moderately, considerably, or extremely difficult.
• Fifty-nine percent of those who asked for assistance in PQRI reporting rated their satisfaction with CMS responsiveness as “no satisfaction” or “low satisfaction.”
• Survey respondents are “discouraged” by their participation in the PQRI program, and “furious” by the inability to find out why they were found by CMS to have not successfully participated in the program.

The survey did not identify why 50 percent of the 2007 PQRI participants did not receive a bonus payment. However, we believe it is several factors:

• NPI Attribution: The 2007 PQRI launched during the transition to NPI. If a physician did not have an NPI on the form, or CMS had not completed the internal processing to confirm that an NPI matched up with a particular physician, the reporting of the quality data codes did not count.
• Measure Validation: If a physician was found by the Measure Applicability Validation Process (MAV) to have been eligible to report on three or more measures but only reported on one or two, the physician did not qualify for an incentive payment. Staff understands from several specialties that the MAV algorithm may be faulty, as some calculations included in feedback reports state a physician should have reported on more measures than were applicable, e.g., an ophthalmologist was found to have needed to report on “assessment of presence or absence of urinary incontinence in women 65 years and older.”
• Complexity of Measures and Coding Errors: Physicians were confused by measure specifications and were not able to understand how their CPT codes needed to match up with the denominator of the measure they were reporting.
• Medicare Carrier Errors: Medicare carrier clearinghouses inadvertently cut off the bottom of some CMS 1500 claim forms, resulting in some quality data codes not being counted. In addition, carriers frequently could not answer physicians’ questions regarding PQRI.
• 2007 PQRI Cap: The 2007 PQRI incentive payments were subject to a cap. This reduced the 1.5 percent bonus payment if physicians reported only relatively few measures or failed to report on at least three applicable measures 80 percent of the time during the reporting period. According to CMS, the cap only applied to 700 professionals participating in the 2007 PQRI. This cap has been eliminated going forward.

Key Lessons Learned From AMA Survey

Early Education and Outreach: AMA is urging CMS to develop an effective educational and outreach program for physicians. Furthermore, CMS needs to train contractors about PQRI so that they may answer physicians’ questions about the program.

Interim Feedback Reports: Confidential interim and final feedback and compliance reports must clearly inform physicians of any reporting errors and how to correct these errors. Congress and CMS must seek input from physicians and other eligible professionals on what content and format would be most instructive. These reports must also be issued on a timely basis. The 18-month lag time between a physician’s initial reporting on July 1, 2007, and receipt of their results in mid-July 2008 did not allow physicians an opportunity to address reporting problems until the reporting period was over. Moreover, the feedback reports were not issued until mid-way through the 2008 PQRI reporting period, which means that many physicians may have been reporting incorrectly in two separate years.

Access to Feedback Report, Problems With IACS: To access feedback reports, individuals (those who do not reassign Medicare benefits to another party) and organizations (those who receive reassigned payments from an individual professional) must register in the Individuals Authorized Access to CMS Computer Services (IACS) system. This system is also tied to Medicare enrollment, and if a physician’s contact information has changed, it may impact a physician’s ability to access their feedback report. CMS must alleviate the undue burden associated with registering for and accessing an IACS account. PQRI feedback reports should be provided via snail mail, email, or telephonically through an automated, password-protected process.

Appeals Process: Physicians who report PQRI measures but who are not deemed by CMS to have successfully reported and therefore do not receive their incentive payments should have the ability to appeal. The Tax Relief and Health Care Act (TRHCA) of 2006 statute explicitly states that there is no appeals process for the PQRI program. Congressional action must be taken to put a process in place that allows physicians to contest the judgment that they did not successfully report.

Next Steps

AMA will be working with Congress and the Administration to secure changes to the PQRI such as the establishment of interim feedback reports and an appeals process. We are also pressuring CMS to rectify the various administrative issues that contributed to the challenges of the program. In addition, AMA requested the 2007 PQRI data set file from CMS. AMA would like to conduct a more detailed review of the 2007 data to better understand possible barriers and stimuli to physician reporting.