Quality as a Revenue Stream

Medicare Quality Initiatives Benefit Patients, Physicians

  Texas Medicine Logo

Quality Feature – April 2011

Tex Med. 2011;107(4):55-58.

By Ken Ortolon
Senior Editor

Garland family physician Cliff Fullerton, MD, is among 129 physicians in the Health Texas Provider Network who recently received a total of $280,000 in bonus payments from Medicare for reporting quality data under the Physician Quality Reporting System (PQRS), formerly known as the Physician Quality Reporting Initiative (PQRI), in 2009.

Dr. Fullerton says the PQRS reporting involved a handful of diabetes-related measures.

"We were able to collect the data right out of our EHR [electronic health record] with really no work for the clinical staff," Dr. Fullerton said. "Physicians may have spent literally five minutes on their component of that reporting."

Texas Medical Association officials say quality improvement allows physicians to increase reimbursements and quality of care in the face of impending cuts in the Medicare program.

PQRS is one of three Centers for Medicare & Medicaid (CMS) initiatives that pay physicians significant bonuses. Texas physicians who have participated say earning the bonuses in at least two of those programs – PQRS and e-prescribing – is relatively easy. The third, achieving meaningful use of electronic health records, is more complicated.

Some physicians don't take advantage of PQRS and e-prescribing because they either don't know about them or believe they will be too much work, says Houston family physician David Auer, MD.

"It sounds like it's going to be a hassle, but it's really amazingly simple," he said.

It's not too late for physicians to get in on the bonuses for 2011. And, physicians need to be aware that if they don't get on board, at least with e-prescribing and EHR adoption, they will be facing financial penalties from Medicare in the very near future. (See "PQRS, eRx Bonus, Penalty Schedules.") 

Reporting Quality

CMS launched PQRS in 2007. It is a voluntary reporting program that pays bonuses to physicians and other eligible health care professionals who satisfactorily report data on quality measures in treating Medicare Part B patients. The program's intent is to get physicians used to documenting and reporting the care they currently provide to patients.

In 2007 and 2008, the bonus equaled 1.5 percent of a physician's total allowed charges for Physician Fee Schedule services during those respective years. That increased to 2 percent in 2009 and 2010. Under the Affordable Care Act, however, the bonuses dropped to 1 percent for 2011 and 0.5 percent for 2012 through 2014.

In 2015, physicians who do not report data to PQRS will see a 1.5-percent reduction in their payments. That penalty increases to 2 percent in 2016 and subsequent years.

To qualify using individual measures, a physician must submit data on at least three measures for up to 30 different patients. If a physician chooses to use measures groups, he or she needs to submit data on just one group for 30 patients. A measures group is a collection of measures that relate to the same clinical condition.

The quality measures cover a wide range of illnesses and chronic conditions, including diabetes, heart disease, osteoporosis, stroke, chronic obstructive pulmonary disease, asthma, and many others.

Initially, the program allowed physicians to submit data on 74 quality measures by placing a special quality code on each claim. Over time, the number of measures expanded to include 170 individual measures and 14 measures groups. To view a list of the quality measures, log on to the CMS website and click on Measures Codes. Reporting now can be done via claims, through a qualified registry, or via EHRs.

TMA officials recommend physicians use a registry to make their reports to give themselves the best chance to earn the incentive payments. They say the registry simplifies the process and allows the doctor to report on just the required 30 patients rather than having to remember to include the special quality code on every claim.

Qualified registries have undergone a CMS vetting process that includes checking their ability to provide the required PQRS data elements, reviewing a measure flow to see whether the registry calculates the measure's reporting and performance rates correctly, and transmitting the required information in the requested file format.

Dr. Auer, a solo practitioner, has participated in PQRS for three years. He twice reported on preventive care measures and once on diabetes measures. He reported through DocSite, which is one of the qualified registries. DocSite describes itself as "an award-winning clinical decision support, quality performance management, and health information exchange company."

Physicians can learn more about registries by visiting the TMA website.  

Dr. Auer says reporting on the preventive care measures was very easy to do. It was a matter of spending a few minutes each with 30 patients to determine whether they were current on such preventive services as colonoscopies or mammograms, then entering the data into DocSite.

Improving Quality

Ghassan Salman, MD, chief medical officer for Austin Diagnostic Clinic (ADC), says his group is in its fourth year of PQRS participation. They started small, with only about a dozen physicians reporting the first year. This year, 88 of the 120 ADC physicians will participate.

ADC reports on diabetes care, mammograms, colonoscopy, heart disease, chronic kidney disease, and more.

He says the PQRS incentive payments may not cover all of ADC's expenses incurred in participating, which include staff time and other overhead costs in collecting the data, as well as distributing some of the bonus funds to ADC's physicians to encourage wider use of evidence-based medicine. But the group sees value in quality reporting.

"There is a concerted effort at ADC to stand behind our core values, which is quality care for all patients," Dr. Salman said. "And our board understands that this effort may not return all the money that we're investing in it, but they're supportive because that's how we differentiate ourselves, by putting the patient first."

If ADC retained all the financial rewards, the bonuses would cover its expenses, Dr. Salman says. "There is no doubt that the return on investment is good, and I encourage every clinic and physician to participate."

Dr. Salman says the amount of the PQRS bonuses that ADC passes on to its physicians is based on their performance. "This encourages evidence-based medicine and leads to improved patient care," he said.

"The physicians have been responsive to the data that we give them," he added. "Some of the measures were not as good as the physicians would like them to be, partly because of documentation. So the physicians have become more aware of documentation."

 Dr. Fullerton, however, says physicians with Health Texas are not really learning a lot about their quality of care from PQRS. That's because the reporting they do in that program is not as robust as the internal data collection and reporting that the group does.

"What we did learn organizationally was about the process of actually doing the report," Dr. Fullerton said. "That was good because going forward CMS is going to require data from us just like they do from the hospitals. So getting that process down was a positive thing."

Dr. Fullerton says Health Texas makes its quality data available to all clinical staff. "We use it to target metrics for overall improvement, such as a 'pop-up' in our EMR [electronic medical record] to start ASA [acetylsalicylic acid] in diabetics 40 and above," he said. "We also use it to give individual attention to low-scoring physicians. It is used by our ambulatory care coordinators to run protocols for patient follow-up and missed testing."

More information about PQRS is online. TMA also offers resources to aid physicians in PQRS participation on its website.

The Electronic Script

The electronic prescribing program, also known as the eRx Incentive Program, is similar to PQRS in that it provides bonuses based on Medicare Part B services provided by participants.

To be eligible for the bonuses, physicians must use a CPT or HCPCS G-code on their Medicare claims indicating that a prescription was prescribed electronically during a minimum of 25 unique patient visits during the year.

For 2010, the bonus for successful e-prescribing was 2 percent of total Medicare Part B services billed. That went down to 1 percent for 2011, and, beginning in 2012, physicians actually will be penalized 1 percent for not prescribing electronically. That goes up to 1.5 percent in 2013. In fact, in order to prevent the 2012 penalty, physicians need to successfully e-prescribe and report the G-code at least 10 times before June 30, 2011.

TMA officials say e-prescribing is the easiest of the incentive programs to comply with if they have the necessary software to transmit prescriptions electronically. Dr. Auer called it "idiot proof."

"It's stupid not to do it," he said. "If people are doing any kind of e-prescribing with an electronic script, then all you have to do is have your billing people put the G-code on there 25 times in a year, and you get the bonus."

Dr. Salman says ADC was already e-prescribing before the program began, so it was easy for them to qualify for the bonus payments. ADC writes the majority of its prescriptions electronically, he adds.

"Patients love it. We have very few patients who want written prescriptions," he said.

Getting Meaningful

Obtaining the incentive payments for meaningful use of certified EHRs is difficult, but the rewards can be substantial. Physicians participating in Medicare who begin demonstrating meaningful use of EHRs in 2011 or 2012 can receive up to $44,000 over five years. That drops to $39,000 for those who meet the criteria beginning in 2013, and $24,000 for those beginning in 2014.

Physicians in Medicaid can see even larger incentives, up to $63,750 over six years.

But those doctors who resist adopting EHRs will see their Medicare payments cut beginning in 2015. Payments will go down 1 percent that year, 2 percent in 2016, and 3 percent in 2017.

Dr. Salman says achieving meaningful use has been difficult and time-consuming for ADC. Just having an EHR system is not enough. Some two dozen criteria have to be met.

"One of the challenges is having a portal through which patients can log in and see part of their medical records," he said. While ADC already had an EHR system, it had to buy the hardware and software necessary to create the portal, he says.

Currently, those portals must give patients access to information on their medications, medical problems, and allergies, he adds. "We estimate that the incentives from meaningful use will exceed the costs associated with the implementation process."

Dr. Auer introduced an EHR into his practice and expects to qualify for the first payment of $18,000 this year. But he says the money is not a "panacea."

Between buying both hardware and software, getting training, and suffering revenue loss while he and his staff got used to the new system, the incentives will be "a wash," he said.

"If I were 10 years older, I would not do it," he added. "If I were in my 50s, I would stick with paper. It's just not worth it."

The good news is physicians can get help in setting up their EHRs for as little as $300 from one of four regional extension centers (RECs) in Texas established to advise physicians on achieving meaningful use. Those RECs are operated by Texas Tech University Health Sciences Center, Texas A&M University Health Science Center, The University of Texas Health Science Center at Houston, and the Dallas-Fort Worth Hospital Council.

The RECs are funded through the Office of the National Coordinator within the U.S. Department of Health and Human Services and provide consulting to help physicians select an EHR system and meet the meaningful use criteria.

More information on the meaningful use incentives can be found on the CMS website. You can also find information about the Texas RECs and help with EHR adoption on TMA's website, as well as information about receiving REC services.

While experts say EHRs have great potential to improve quality of care, recent results have been mixed. According to a study published in the Journal of the American Medical Informatics Association in August 2009, researchers found no difference in performance between EHR users and nonusers. In addition, there was no consistent pattern linking length of time using an EHR and physicians' performance on recognized quality measures

However, a 2009 study published in the Annals of Internal Medicine found that EHRs were associated with higher performance across multiple Healthcare Effectiveness Data and Information Set quality measures.

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail.


PQRS, eRx Bonus, Penalty Schedules

Physicians and other eligible health care professionals who satisfactorily report quality measures data earn an incentive payment equal to a percentage of their estimated total allowed charges for treating Medicare Part B patients under the Physician Quality Reporting System (PQRS). Those who do not report quality data will see reduced payments.

Bonus and penalty rates are:  

  • 2011 – 1 percent
  • 2012 – 0.5 percent
  • 2013 – 0.5 percent
  • 2014 – 0.5 percent
  • 2015 – minus 1.5 percent
  • 2016 – minus 2 percent  

Physicians who successfully prescribe electronically also could see a bonus, while those who don't could see a penalty on their Medicare Part B payments. Those bonuses and penalties beginning in 2011 include:   

  • 2011 – 1 percent
  • 2012 – minus 1 percent
  • 2013 – minus 1.5 percent

Back to article

April 2011 Texas Medicine Contents
Texas Medicine Main Page