Government PQRI Quality Reporting Program Getting Short Shrift from Oncologists

PQRI - Little ParticipationAlthough most oncologists believe in quality improvement, their participation in the federal government's Physician Quality Reporting Initiative remains low. Now in its third year, the voluntary PQRI program offers payments of 2% on a physician's total Medicare charges in exchange for successful reporting of certain quality measures. In 2009, PQRI paid out about $92 million to more than 85,000 physicians and other eligible professionals who successfully reported quality data to Medicare. The Centers for Medicare & Medicaid Services does not track the number of oncologists who are participating, but observers say they think most oncology practices are sitting on the sidelines—first, in participation; and second, in revenue generation from the program. Matthew Farber, MA, Director of Provider Economics and Public Policy for the Association of Community Cancer Centers, said he routinely inquires about PQRI participation when ACCC members gather for meetings. “Typically it's no more than a quarter of the hands that are raised,” he said. “I then ask how many have received a bonus payment from PQRI, and that is maybe 5% of the hands that were raised.” Oncology Hematology Care Inc., with more than 40 oncologists and nurse practitioners in Cincinnati, falls in the PQRI category of participating-but-not-seeing-any-money, said Michael Neuss, MD, a member of that practice.TABLE: Reasons Physician Practices Gave for Participating in 2009 Physician Quality Reporting InitiativeTABLEDr. Neuss chairs the Clinical Practice Committee and is a member of the Quality of Care Committee for the American Society of Clinical Oncology. In preparing for an interview about PQRI, he asked oncologists at a few other large practices about the program. Although one of the practices had never tried to participate, the other two shared Oncology Hematology Care's frustrating experience.MICHAEL NEUSS, MD, a member of ASCO's Quality of Care Committee, said that the general feeling among oncologists is that PQRI is a lot of work and is not meaningful work—“It seemed like free money, so many of us have tried it, but it has not worked out.”“The general feeling among oncologists is it's a lot of work and it's not meaningful work,” he said. “It seemed like free money, so many of us have tried it but it has not worked out.” Why One & Not the Other? Hematology-Oncology Care of the Northern Rockies has participated in PQRI since its inception. With three locations in Montana and Wyoming, the practice includes seven physicians and two physician assistants. Although data were submitted for all providers in 2007, only one physician earned a PQRI bonus check. “There wasn't any way to figure out why one of us got paid and the rest of us didn't,” said Patrick Cobb, MD, a partner in the practice. “We submitted the data the same way for everybody.” In the second year, every member of the practice received a PQRI bonus. The practice is now in its third year of participation, and Dr. Cobb recently asked his colleagues what they think about the program. “I polled some of my partners—‘what do you know about PQRI?—and most of them said they don't know anything about it,” he said. “I asked ‘Did it make any difference in the way you practice?' They said ‘no.’” Like his partners, Dr. Cobb, President of the Community Oncology Alliance, considers PQRI to be a potential source of extra revenue that is unrelated to the quality of care.MATTHEW FARBER, MA, Director of Provider Economics and Public Policy for the Association of Community Cancer Centers, said he routinely inquires about PQRI participation when ACCC members gather for meetings. “Typically it's no more than a quarter of the hands that are raised,” he said. “I then ask how many have received a bonus payment from PQRI, and that is maybe 5% of the hands that were raised.”“It is something that our billing people take care of,” he said. “As far as using PQRI to improve the quality of care in the United States, it is not meeting that goal.” Incremental Approach CMS's approach is to incrementally introduce value-based purchasing by letting physicians learn how to submit data and eventually start holding them accountable for what that data says about their practice patterns. But that approach may have unintended consequences because physicians do not see it as relevant to their daily activities. Dr. Neuss' Cincinnati practice is continuing to participate in PQRI, hoping that the third year brings success. “We are committed and we are trying very hard to make it work in 2010,” he said. “But it is hard to get people to pay attention to things that have very little to do with improving patient care.” Other Quality Initiatives The paradox of oncologists' low participation in PQRI is that cancer specialists are more attuned to quality reporting than many other specialists. COA lobbied to get a national quality cancer care demonstration project included in the health care reform legislation signed into law in March. Dr. Cobb said he still hopes the proposal, which was not included in the health reform act, might gain traction. That demonstration would test the idea of paying bonuses to oncologists who report whether they follow evidence-based guidelines for treatment planning and end-of-life care.PATRICK COBB, MD, President of the Community Oncology Alliance: “I polled some of my partners, asking, ‘What do you know about PQRI?’ and most said they don't know anything about it. I asked, ‘Did it make any difference in the way you practice?’ They said ‘no’…. It is something that our billing people take care of. As far as using PQRI to improve the quality of care in the United States, it is not meeting that goal.”“The guidelines are freely accessible, and they are peer reviewed,” Dr. Cobb said. “We feel if oncologists would be incentivized to [follow guidelines], it would make a lot more sense than it does to report the PQRI items.” QOPI Meanwhile, Dr. Neuss points to ASCO's Quality Oncology Practice Initiative (QOPI) as a quality benchmarking program as an alternative to PQRI. More than 300 oncology practice sites submit performance data to the QOPI program for at least one of the two reporting periods each year. ASCO analyzes the data to determine how well a practice adheres to more than 80 evidence-based and consensus standards. “QOPI allows oncologists to evaluate not their reporting ability, but their actual performance,” he said. “I am suggesting that QOPI could and should be recognized [by CMS] as a mechanism for demonstrating quality of oncology practices.” Modifications/Alternative? ACCC's Farber said he believes it is too early to know whether physicians' lack of interest in PQRI will force modifications to the program or the adoption of an alternative. But he is clear that physicians need to become proficient at quality reporting because their financial future depends on it. “We may see more of a penalty-based system versus a bonus pay system, but the idea of tying pay to quality is a payment model that is here to stay,” he said. “Whether it's PQRI, a modified PQRI, or something else entirely, oncologists should get in the mindset that they're going to have to report more on quality as we go forward.” PQRI Explained Established by Congress at the end of 2006, the Physician Quality Reporting Initiative is the government's biggest effort so far to move physicians toward a value-based purchasing, in which CMS will pay for the quality and efficiency of care delivered, rather than on the quantity of services provided. The PQRI program is a baby step oward measuring a physician's value because it rewards physicians not for their actual performance on quality measures but rather their reporting on those measures. The incentive started at 1.5% of a physician's total Medicare charges in the first two years of the program—2007 and 2008—and increased to 2% for those in submitted data in 2009. To date, there have been two payouts: $36 million to physicians who successfully participated in 2007. $92 million for those who participated in 2008. For the 2008 participants, the average incentive amount per physician topped $1,000. But that is just one side of the PQRI story. More than 153,600 physicians participated in the 2008 PQRI, but nearly 45% received no money for their efforts. The main reasons: incorrect or insufficient data submission. CMS officials, who had to develop and launch the Congressionally mandated program in just a few months' time, have acknowledged technical difficulties in the first year, when quality data had to be submitted with Medicare claims. Since then, CMS has improved the program, said Michael T. Rapp, MD, JD, Director of Quality Measurement and Health Assessment Group at CMS. Data can now be submitted through a registry or electronic health record technology, both of which make data submission easier and the likelihood of successful reporting more likely. How to Participate It is not too late to participate in PQRI for 2010. Those oncology practices that have not yet participated can submit data for the July 1 to Dec. 31 reporting period. There is no registration. Just start reporting the measures through Medicare claims or one of the approved registries; data submission through electronic health record technology was an option for the full-year reporting period, but it is not available for the six-month reporting period. Michael T. Rapp, MD, JD, Director of Quality Measurement and Health Assessment Group at CMS, reports that physician practices that submit data using a registry have a higher success rate than those who submit data via claims. A list of approved registries is at http://www.cms.hhs.gov/PQRI/Downloads/QualifiedRegistriesPhase1eRx020110.pdf To qualify for an incentive payment—2% of total Medicare charges—a physician must submit data on at least 80% of applicable patients on at least three individual quality measures. Physicians should choose measures that are applicable to the greatest percentage of their patients. The 2010 PQRI measures list is at http://www.cms.hhs.gov/PQRI/Downloads/2010_PQRI_MeasuresList_111309.pdf The incentive payments for successful participation in 2010 will be issued in July 2011. Contact the QualityNet Help Desk (866-288-8912 or [email protected]) for help getting started.

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