ANESTHESIOLOGIST AND CRNA PARTICIPATION RATES IN THE PHYSICIAN QUALITY REPORTING INITIATIVE (PQRS), AND NEW COMPENSATION DATA
April 25, 2011
Anesthesiologists had the second-highest rate of participation in the PQRS (then known as the PQRI, or Physician Quality Reporting Initiative) in 2009. Nearly 17,500 anesthesiologists, or 41.1% of those eligible, reported PQRS measures on their Medicare claims, second only to emergency physicians (62.8%). The average participation rate for all eligible professionals was 20.91 percent. Almost 12,000 nurse anesthetists, or 29.3% of eligible CRNAs, participated in the program.
In its recent paper 2009 Reporting Experience Including Trends (2007 – 2010): Physician Quality Reporting System and Electronic Prescribing (eRx) Initiative and its appendix of data tables, CMS speculated on the reason, stating: “Hospital-based practices most likely have current processes in place to capture clinical data accurately therefore allowing quicker uptake of reporting quality measure data.”
Timely administration of antibiotic prophylaxis, Measure #30, was among the ten measures for which providers satisfied the minimum reporting threshold most often. The minimum reporting threshold was 80% of all eligible cases. In general, it has proven difficult for physicians to meet that threshold. In 2009, 49% of eligible professionals submitting some valid measure data did not report on 80% of the eligible instances.
Slightly fewer than half of anesthesiologists (46.2%) and slightly more than half of CRNAs (53.7%) who submitted any claim(s) with a valid PQRS “quality data code” earned the incentive bonus—a success rate that nevertheless placed the two categories of professionals in the top ten. The principal reason for failing to earn the bonus is reporting PQRS measures on fewer than 80% of eligible cases. Although 71.72% of eligible professionals attempted to report on Measure #30, only 38.07% reported a valid quality data code, and only 55.29% of those professionals reported Measure #30 in at least 80% of their eligible cases. Other reasons for not qualifying for the bonus include reporting on fewer measures than apply to one’s practice (in 2009, only the antibiotic prophylaxis measure was available to most anesthesiologists) and submitting claims with quality data coding errors such as incorrect procedure or diagnosis codes.
Overall, 49.8% of all eligible professionals reporting PQRS data as individual rather than group measures, through claims rather than registries – the only option available to most anesthesia providers -- earned an incentive in 2009. CMS paid out a total of more than $234 million to 119,804 physicians and other eligible professionals in 12,647 practices. Of the $234 million, 2.91% went to anesthesia providers—a little more than anesthesiology’s proportion of Medicare spending on physician services. The average bonus paid to anesthesiologists was $836.58. The corresponding amount for nurse anesthetists was $403.11.
Among physicians, only pediatricians, psychiatrists, obstetricians/gynecologists and oral and maxillofacial surgeons had lower average bonuses. The overall average payments were $2,274 per eligible physician. The difference between the payments to anesthesiologists and the average amount paid to other specialists whose payer mix is 20% or more Medicare calls for an explanation, but the CMS paper does not provide one. Nor does it address the important question why actual payments to many providers differed from the expected payments.
In a press release issued announcing the paper on April 19, 2011, CMS Administrator Donald Berwick, M.D. commented on clinical performance improvement as measured by the PQRS:
CMS is encouraged by data from the Physician Quality Reporting System that shows growing rates in how often health care professionals report that they are complying more often with evidence-based care practices. These increased reporting rates could signal a positive trend in the quality of healthcare Medicare beneficiaries receive from professionals who report data through the [PQRS].
The PQRS was designed to reward reporting quality data; the bonus is not based on performing the measures but on reporting whether one has or has not performed. The improvement noted by Dr. Berwick reflects decreases in the use of the modifiers indicating that the provider has not performed the quality intervention. For example, an anesthesiologist may add modifier -8P to the quality data code for Measure #30, which signals “Prophylactic antibiotic was not given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required), reason not otherwise specified.” The shift from reporting non-performance to performance may demonstrate greater confidence in the PQRS coding system as much as it reveals improvements in outcomes or even in processes of care. For whatever reason, the reported rates of performance have increased by an average of 3.1%, based on recent claims data on the 55 measures that have been a part of the PQRS since it began in 2007. On the 99 measures that were in the PQRS in 2008 and 2009, performance rates have increased by approximately 10.6% on average.
Two years from now, CMS will begin reporting PQRS data on its Physician Compare website. Those data require a good deal of explanation regarding what was reported and the relevant denominators. It is difficult to see how Medicare beneficiaries will be able to draw meaningful conclusions, but some form of the PQRS data is going to be made public.
Bonus data—compensation: According to Jackson & Coker’s 2011-2012 Provider "Contribution to Operations" Percentage Calculator, national average revenues generated by anesthesiologists are 5.5 times greater than their national average total compensation.
Table 1. Anesthesiologists’ Contribution to Operations
(Source: Jackson & Coker)
The compensation values in Table 1 are national averages, based on 28,640 anesthesia providers in the Jackson & Coker database. Local salaries will vary. Among the specialists who are more highly compensated than anesthesiologists, according to the database, are neurosurgeons ($713,829 total national average), orthopedic surgeons ($600,834), non-interventional radiologists ($532,760), cardiologists ($491,493), gastroenterologists ($482,090) and urologists ($479,169).
Aggregate data on anesthesia practice are usually somewhat problematic. For one thing, the sample (or denominator) is skewed or even indeterminate, as in the case of most ASA and MGMA survey data where the pool of potential respondents is unknown. Definitions of variables are either too general or excessively detailed a result of the diversity of anesthesia groups and their management methods. The most reliable data come from one’s own practice. Comparative statistics are frequently necessary, though. The best approach is to perform a meta-analysis of all available data so as to identify patterns across various sources. We hope that the information provided in this Alert will be of interest to you.
With best wishes,
President and CEO