Anesthesiologists and pain physicians who have been receiving bonuses for participating in Medicare’s Physician Quality Reporting System (PQRS) should continue to do what they have been doing. The proposed Fee Schedule rule (NPRM) for 2013 does not contain any new requirements affecting those who are already successfully participating, as we noted summarily in last week’s Alert.
For physicians who have yet to earn a PQRS incentive payment, the NPRM would make reporting easier in future years. This is important, because failure to report PQRS measures will result in financial penalties beginning in 2015—based on reporting in 2013. The amount of the payment adjustment, positive or negative, will be as follows:
CMS has stated that one of its major goals in developing its proposed changes was to increase participation to 50% of eligible providers in 2015. In 2010, the overall level of participation was only 24 percent. (“2010 Reporting Experience, Including Trends (2007-2011): Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive Program,” Centers for Medicare & Medicaid Services, Feb. 22, 2012.) More than 125,000 physicians met enough of the requirements to share a total of nearly $400 million in individual incentive payments. More than 50,000 tried for the bonuses but did not report enough quality measures to meet the minimum requirements. Anesthesiologists had the second highest specialty reporting rate among eligible providers using claims-based reporting methods (20,040 out of 42,125 physicians, or 47.6%) and CRNAs the sixth highest rate (14,274 out of 41,199 nurses, or 34.7%). Emergency medicine came in first, at 65 percent. The relatively greater use of electronic patient records by hospital-based physicians may explain the greater success of these specialists in qualifying for the PQRS bonus.
It is reasonable to assume that the reporting rates have increased significantly since 2010; the number of eligible professionals who participated individually went up by 16% from 2009 to 2010. Still, even if the number of participating anesthesiologists increased by 25% from 2010 to 2012, there would still be more than 16,000 anesthesiologists who would not have the experience of successfully reporting PQRS measures before 2013. The corresponding number for CRNAs would be 22,642.
Anesthesiologists and CRNAs who are not yet reporting PQRS measures need to prepare to report a minimum of three measures, unless fewer than three apply to their individual practices, in which case they will qualify to avoid the payment penalty if they report one or two measures depending on whether one, or two, are applicable. They must report each measure for at least 50 percent of their Medicare patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted. Three measures (in particular) potentially apply to anesthesia practice:
|# 30||Timely Administration of Prophylactic Parenteral Antibiotics|
|# 76||Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion|
|#193||Perioperative Temperature Management|
Despite an increase in the number of measures available for individual reporting in 2013 to 264, in a total of six domains including Patient Safety and Care Coordination, CMS has not approved any new measures for anesthesia or pain management. Note that measures are not restricted in their use by specialty, however. If a clinician provides the service, identified by CPT code, in the measure’s denominator (e.g., all outpatient visit codes) and meets all of the documentation requirements for the numerator (e.g., documenting all the patient’s medications by name, dosage, frequency and route, Measure #130), that clinician can report the measure. Thus other measures that may apply to an anesthesiologist's or pain physician's practice include the following:
|# 44||Preoperative Beta-Blocker in Patients with Isolated CABG Surgery|
|# 47||Advanced Care Plan|
|#109||Osteoarthritis (OA): Function and Pain Assessment|
|#130||Documentation of Current Medications in the Medical Record|
|#131||Pain Assessment and Follow-Up|
|#142||Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over the Counter (OTC) Medications|
|#173||Unhealthy Alcohol Use – Screening|
|#226||Tobacco Use: Screening and Cessation Intervention:|
The specifications for each of these measures are available on the CMS PQRS web page. It is critical to consult the specifications because they will determine whether a clinician can potentially report the measure. Not all of the measures listed above will apply to an individual anesthesia or pain practice. But by reporting a measure even one time, a physician declares that measure applicable to his or practice. Unless that doctor reasonably expects to be able to report each measure in at least 50% of the relevant cases, it does not make sense to accumulate reportable measures.
For 2013, CMS has proposed a new measure for “Participation by a Physician or Other Clinician in a Systematic Clinical Database Registry that Includes Consensus Endorsed Quality.” The clinician must report at least three measures to the registry and report each measure for at least 80% of his or her Medicare patients. Many anesthesiologists are already submitting data to the Anesthesia Quality Institute’s (AQI’s) National Anesthesia Clinical Outcomes Registry (NACOR), and they will be able to report the proposed measure if it is adopted in the final regulation, which is due to be issued on November 1, 2012. AQI Executive Director Richard P. Dutton, MD, MBA, states: “ASA and the AQI are committed to ensuring that practicing anesthesiologists are able to participate in PQRS reporting. The AQI is a certified reporting registry for PQRS measures, and can facilitate submission of measures to CMS for participating practices. The AQI will continue to work with ASA's Committee on Performance and Outcome Measures to develop and update measures intended for public reporting.”
Measure #124, Adoption/Use of Electronic Health Records (EHR), is on the list of “Measures Included in the 2012 PQRSs Measure Set that are Not Proposed to be Included in the Physician Quality Reporting Program Measure Set for 2013 and Beyond.” We mentioned #124 as a potential measure for anesthesiologists and pain physicians in our last Alert on PQRS issues (December, 2011). The individual measure would be dropped because CMS is seeking to align the PQRS and EHR incentive programs.
The number of measures groups has also increased, from 21 to 22 in 2013 and to 26 in 2014, but there are still no measures groups applicable to pain management or anesthesia practice.
Methods of Reporting
CMS has proposed to expand the options for reporting PQRS measures in a number of ways, consistent with its announced goal of “Eas[ing] eligible professionals into reporting for the PQRS payment adjustment by providing alternative means to avoiding the 2015 and 2016 payment adjustments.”
Currently there are four distinct mechanisms for reporting: claims-based, through a qualified registry, by direct EHR product and indirect EHR data submission vendor and the group practice reporting option (GPRO) using a web interface. More than 90% of the clinicians who reported in 2010 reported by adding a five-digit “Quality Data Code” (QDC) to their claims.
Proposed changes and additions to the other methods of reporting individual (not group) measures are as follows:
- GPRO—2013 onwards:
CMS proposes to include groups of 2-24 eligible professionals (EPs) in the definition of “group practice,” previously limited to groups of 25 or more EPs.
Group practices must use the web to submit self-nominations to participate in the optional GPRO. (CMS proposes no longer accepting written letters accompanied by an electronic file.) Groups of 2-99 EPs participating in the optional GPRO would be able to report data on quality measures using claims, registry and EHR-based reporting mechanisms, and not just the web-interface reporting mechanism, for which there are 19 proposed measures and which is the only method available now.
Groups of 25 or more EPs would continue to have available the web-interface mechanism, which would be the only acceptable method for groups with 100 or more EPs.
- Direct EHR Product and EHR Data Submission Vendor:
Option 1: Eligible professionals must report on 3 Medicare EHR Incentive Program core or alternate core measures, plus 3 additional measures. Since the EHR core and other measures do not apply to anesthesiology or pain medicine, readers should instead consider:
Option 2: Report at least three individual measures; and report each measure for at least 80% of the EP’s Medicare patients. Optional GPROs of 2-99 EPs must report three or more measures for at least 80% of the group’s Medicare patients.
Option 1 subdivides into Option 1a and Option 1b. Both require reporting measures that do not fit anesthesiology or pain practice. Again, though, Option 2 (minimum of three measures and 80% of patients) is available for groups with a qualified EHR system or EHR data submission vendor.
Although CMS has previously required direct EHR products and EHR data submission vendors to undergo a qualification process, beginning 2014, CMS is proposing not to continue the qualification process. Instead it will be up to the practices that contract with EHR vendors to ensure that the EHRs.
- Single measure for EPs who begin reporting in 2015-2016
To ease the experience for providers who have not previously participated in PQRS, CMS proposes that satisfactorily reporting in 2015 and 2016 (the first years of payment adjustments) includes the option of just reporting one measure or measure groups using the claims, registry or EHR mechanisms.
- Simplified administrative claims-based reporting in 2015-2016
Unlike the traditional claims-based reporting option, an eligible professional or group practice would not be required to submit QDCs on claims to CMS for analysis. The EP or the group could instead elect to use a new, pure administrative claims method of participating in the PQRS: CMS would analyze every EP’s or CMS-selected group practice’s patients’ Medicare claims to determine whether the EP or group practice has performed any of the clinical quality actions indicated in a subset of 19 measures that CMS believes “are clinically meaningful, focus on highly prevalent conditions among beneficiaries, have the potential to differentiate physicians, and be statistically reliable.” NPRM July 6, 2012, p. 522. The proposed subset appears in Table 63 on p. 523. All 19 measures will be reported and analyzed in 100% of cases in which they apply, which makes sense given that the measures reflect population-based observations and require no action on the part of the clinicians. To illustrate, three of the measures are:
- Percent of the population with admissions for congestive heart failure
- The number of discharges for long-term diabetes complications per 100,000 population age 18 Years and in a one year time period.
- The rate of provider visits within 30 days of discharge from an acute care hospital per 1,000 discharges among eligible beneficiaries assigned.
The only action required of the EP is to inform CMS that he or she elects the administrative claims-based method. The method will only be available—if it is finalized—during the reporting periods for 2015 and 2016.
For the vast majority of anesthesiologists and pain physicians, successfully participating in the PQRS is probably simpler than wading through the annual hundreds of pages of proposals for changes from CMS. We at ABC have done our utmost to make the process as simple, and for as many of our clients, as possible. We hope that the information we continue to provide will assist all our “EP” readers to qualify for the incentives through 2014 and to avoid the payment adjustments that begin in 2015.