Medicare's Latest Missteps Further Frustrate Physicians Over Increasingly Complex Federal Quality Reporting Programs. 

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Quality Feature — March 2016

Tex Med. 2016;112(3):59-62.

By Amy Lynn Sorrel
Associate Editor

For several years, Michael Ragain, MD, has invested countless hours and dollars learning the ins and outs of Medicare's quality reporting programs. The Lubbock family physician tracks and selects applicable measures of his patients' health, uses an electronic health record (EHR) system set up to properly capture and submit his groups' performance, interprets complex feedback reports, and makes practice adjustments along the way to avoid the payment penalties for noncompliance and poor scores.  

None of that mattered late last year when Medicare announced technical difficulties on its end collecting and analyzing the 2014 data physicians like Dr. Ragain painstakingly submitted to the Physician Quality Reporting System (PQRS) and the value modifier (VM) program. (See "Alphabet Soup.")

The result: At least one-quarter of participating physicians risked Medicare payment cuts stemming from the miscalculations, the American Medical Association estimates, including practices like Dr. Ragain's that successfully reported in the past. Payment cuts are based on data submitted two years earlier, so 2016 payments stem from 2014 data, for example. 

The Texas Medical Association won't be able to gauge the full impact of the problem in Texas until the Centers for Medicare & Medicaid Services (CMS) releases its annual PQRS experience report, typically in the spring, officials say.

Instead of getting rewarded for the work he'd already done, Dr. Ragain was in for more.

First, his primary care group and another at University Medical Center (UMC) Health System got reports saying CMS could not accept the 2014 quality data they submitted. The affected physicians then got letters saying payment penalties were on the way — up to 4 percent of their Medicare income. Following more conflicting and confusing information from CMS, Dr. Ragain finally got clear guidance from TMA that he still would have to appeal the penalties in order to reverse them. 

"If I make an error in my practice, I have to tell the patient and take responsibility and often write off the charges associated. They [Medicare] make an error, and I have to appeal or I get a penalty, plus the expense of the EHR to do the reporting. It's frustrating, and it's not fair," he said.

Fortunately, TMA and AMA won extra time for doctors to evaluate their penalty status and appeal. But medicine continues to press CMS to stop the merry-go-round of problems with Medicare's transition to value-based payment that continue to discourage physicians from participating.

"You start to feel like it's not really about the quality piece, and it's more about the financial piece," said Dr. Ragain, a member of TMA's Council on Health Care Quality. In light of the recent missteps and the fact that Medicare's quality programs are not going away any time soon, he adds this warning for doctors: "If you are not really keeping up on this, it can easily get by you and through no fault of your own."

The Not So Merry-Go-Round

Despite their best efforts to keep up with Medicare's multifarious value-based payment programs, physicians remain at their mercy. 

TMA and AMA tracked the latest technical issues back to last summer, but Medicare has yet to fully come clean about what caused the problems and how widespread they are, saying only, "there were issues with data submitted via EHR and qualified clinical data registry, as well as a technical issue with the claims used to calculate claims-based measures." CMS said it "successfully corrected" the issues and produced revised PQRS and Quality and Resource Use Reports (QRURs) with updated scores, and "for a small percentage of groups, this correction resulted in a change to their [value modifier] calculation." 

In 2016, only physicians in practices with 10 or more eligible professionals are subject to potential VM penalties based on 2014 performance. The VM hits payments for all physicians as of 2017, based on performance as of 2015.

TMA and AMA officials say CMS' recalculation process resulted in lower performance scores for many physicians, with more doctors at risk of payment cuts in 2016.

CMS' response did not come until Nov. 16, 2015, months after CMS published faulty feedback reports in early September, and days before Medicare's first extension of the deadline for physicians to appeal from Nov. 9 to Nov. 23. Texas Medicine also has reported in the past about the difficulties physicians already face accessing their feedback reports. (See "Technical Assistance Required," September 2015 Texas Medicine, pages 59-62.) 

Medicine won an extension of the deadline to appeal — known as an informal review — until Dec. 16, 2015. But TMA and AMA continued to urge federal leaders to enact a "hold harmless" policy automatically exempting all physicians who attempted to comply with the PQRS requirements from any penalties. At the very least, medicine advocated CMS give doctors more time to appeal in 2016 so they can review their reports. 

"It has, unfortunately, become routine for me to write you on behalf of the more than 48,000 physician and medical student members of the Texas Medical Association, seeking relief from some ridiculous edict from the CMS. They've done it again, and so I return with this entreaty. The latest victims are those physicians who are actually trying to comply with CMS' convoluted pay-for-performance rules," TMA President Tom Garcia, MD, wrote in a Dec. 8, 2015, letter to the Texas delegation in Congress.

The plea came on the heels of a Dec. 1 missive from AMA Executive Vice President and Chief Executive Officer James L. Madera, MD, to CMS Acting Administrator Andrew M. Slavitt conveying, "CMS' failure to provide transparent, clear, and timely information on the various data problems and the system glitches that have impeded accurate calculation of 2016 adjustments has led to mass confusion. Many physicians still are not aware that they are facing significant Medicare payment reductions that they could, and should, contest. Consequently, providing them with three additional weeks to file such requests is simply not a sufficient solution to address this problem."  

Medicare has since charged ahead with the flawed programs, at the same time expecting physicians to prepare for Medicare's next iteration of value-based payment set to come in 2017: the Merit-Based Incentive Payment System (MIPS). Despite medicine's warnings, Medicare also moved ahead in December with expanding Physician Compare — a public website displaying quality ratings derived from physicians' quality performance scores — to include individual physicians, not just groups. 

"Given the widespread accuracy issues with the 2014 PQRS calculations, the newly released [Physician Compare] information is premature," AMA President Steven J. Stack, MD, said. "The AMA is a strong supporter of transparency, but today's action goes in the opposite direction — offering the public information that will lead consumers to draw faulty inferences about the quality of care that an individual physician or group provides."  

In a string of blog posts last December, CMS says it is working to streamline and reduce burdens in its quality programs, including improving data submission, measures development, and standards for EHR use, particularly with the transition to MIPS. TMA is actively involved in the various ongoing comment processes. Too, Medicare recently created a new PQRS Web-Based Measure Search Tool for claims and registry-based measures. 

On Dec. 31, CMS followed up with an announcement about an error with a diabetes measure.  

On Your Own

Dr. Ragain says the quality programs are getting more, not less, complicated, and physicians are pretty much on their own to figure it out. 

The UMC physician groups had reported successfully in the past, so when they started receiving penalty letters, "that got people pretty worked up," he said. The groups filed an informal review and successfully reversed the penalties, "but we had to do some work to find out what was going on, and we're lucky that we have an office that focuses on quality and can keep following up on these issues. Otherwise, we never would have known about the errors." 

As chief medical officer at UMC Health System, Dr. Ragain also regularly reviews his QRURs to see his quality and cost scores and where there might be room for improvement. (See "Review Your Quality Reports.") The latest report CMS released was completely different from the last two he received, not to mention wholesale changes to certain quality measures based on old data. 

"Golly, can't they just be consistent? They keep plugging in things that are new, and we have to do a lot of research to find out what they mean. I don't know how many hours I've spent, but it's many," Dr. Ragain said. 

TMA and TMF Health Quality Institute — the Medicare-contracted statewide quality improvement organization and network — have assisted on some appeals related to the technical issues. But concerns linger over whether physicians knew enough about the problems in the first place to pursue a review. 

TMA and AMA have assisted physicians whose letters from Medicare explaining the technical issues didn't arrive until late November, after the initial informal review period ended. The undated letters did not explain the penalty, saying only that physicians had 60 days to file an informal review request and neglecting to mention the clock started in September, when CMS released the original, flawed feedback reports. "As a result, physicians receiving the letters have no idea of whether they should or should not file a request for Informal Review, or what to address in such a review," AMA's letter states.

TMA officials also clarify that simply filing an informal review does not mean CMS will automatically reverse any penalties. 

In fact, the association has received reports from members and vendors of doctors getting dinged for what TMA Director for Clinical Advocacy Angelica Ybarra describes as minor mistakes that were out of their control. 

Last year, for instance, CMS denied several TMA physicians their final incentive payments for incorrect reporting after the agency renumbered a measure related to coronary artery disease. (Incentive payments ended in 2014.) The measure did not change, but the number did. Physicians' data were right, but the one measure number they submitted was wrong.

The physicians successfully appealed and updated their submission, but Medicare only agreed to remove the related penalties; the agency refused to pay doctors any incentive payments due. 

Ms. Ybarra recommends physicians start their reporting as early as possible, including selecting a reporting method and applicable measures. 

She says CMS' new measure search tool is a good start. Find additional help in this TMA Practice E-Tip

Ms. Ybarra also urges all physicians to sign up for CMS' PQRS listserv

Dr. Ragain turns to TMA's educational tools to navigate Medicare's confusing web of quality programs and to TMF for more technical help on performance improvement. He also suggests physicians stay engaged. 

"I certainly aspire to be high quality and care very much about my outcomes with patients. And most doctors want to provide high quality, and if they get data that's understandable, they will modify their behavior to do better," Dr. Ragain said. But Medicare has to do its part, too, he says. CMS quality programs "need to be clean, and simple, and standard, and when they keep changing things up, we are completely back to square one." 

Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


Alphabet Soup 

PQRS: Physician Quality Reporting System
Medicare penalty-based program requiring physicians to document and report on clinical quality measures. The scores feed into the value-based payment modifier. 

VM: Value-based payment modifier
Medicare calculation to adjust physician fee-for-service payments up or down based on how they perform on cost and quality factors. 

QRUR: Quality and Resource Use Report
Medicare feedback reports on physician quality and cost performance and how they compare to their peers. 

MIPS: Merit-Based Incentive Payment System
Alternative value-based payment system created under legislation that eliminated the Medicare Sustainable Growth Rate formula. It combines these current quality programs: PQRS, VM, and meaningful use, Medicare's electronic health records incentive program. 

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Review Your Quality Reports

Have you seen your quality reports? Here's how to access them:  

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Apply for Meaningful Use Hardship Exception by March 15

It's no secret TMA has been less than thrilled with the meaningful use electronic health record (EHR) incentive program. For starters, the Centers for Medicare & Medicaid Services (CMS) did not publish the modification rule for Stage 2 meaningful use until Oct. 16, 2015. As a result, eligible professionals weren't informed of the revised program requirements until fewer than the 90 required days to attest remained in the calendar year. That left them at risk for a penalty. 

CMS vowed to grant hardship exemptions for 2015 for those eligible physicians who were unable to attest due to the lateness of the rule. In December, Congress adopted S 2425, known as the Patient Access and Medicare Protection Act, which allows one exception form for groups and individual physicians so they can list all physicians and other health professionals who are claiming the same exemption category.    

If the 2015 meaningful use modification rule delay prevented you from meeting the criteria for the 2015 reporting year, listen up. You need to review the hardship application categories to see if any of them apply to you. Categories include: 

  • Insufficient Internet connectivity, 
  • Extreme and uncontrollable circumstances, 
  • Lack of control over the availability of certified EHR technology, and 
  • Lack of face-to-face patient interaction.  

An exemption will have an impact on your 2017 payments only. You must reapply for exemptions each year. 

You have until March 15 to submit the hardship application. CMS provided some additional information on the hardship exception instructions.  

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May 25, 2016

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