July 6, 2010

Important PQRI Changes for Anesthesia Practices

CMS has released the 1250-page proposed rule containing changes to the Medicare Physician Fee Schedule for 2011. Chief among these changes is the calculation of next year’s conversion factor. By now you have probably heard that the proposed rule would cut payments by another 6.1 percent, effective January 1, 2011. We want to be sure you know that this is not a real number. It is driven by the Sustainable Growth Rate (SGR) formula and certain proposed shifts in relative values between various specialties. The final percentage change in the 2011 conversion factor will almost certainly look very different, for these reasons:

• On June 24th, the day before the proposed rule was released, Congress passed the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 (H.R. 3962). This legislation retroactively postponed the effective date of this year’s 21.3 percent SGR cut until December 1, 2010, and established a 2.2 percent increase over 2009 rates for the period July 1-November 30;
• Congress is going to remain under considerable pressure to eliminate the SGR altogether, and
• The 6.1 percent decrease reflects proposed relative value shifts and other payment policy changes that may be revised after CMS reviews the many letters it will receive before the August 24th deadline for “comments” on the proposed rule.

In other words, don’t assume that the 6.1 percent reduction will necessarily stand, but do use it to support your arguments to your Congressional representatives that they must fix the SGR.

Proposed Rule’s Changes to the PQRI

The proposed rule would implement a number of the provisions of the Patient Protection and Affordable Care Act, which has become known simply as the “Affordable Care Act.” Of particular interest are the modifications to the Physician Quality Reporting Initiative (PQRI). To begin with, the bonus for successfully reporting the measures applicable to one’s practice will decrease from 2 percent of Medicare allowed charges to 1 percent in 2011 and to just 0.5 percent in 2012, 2013 and 2014. In 2015, not reporting PQRI measures will net physicians a 1.5 percent decrease in their Medicare payments, and a 2.0 decrease beginning in 2016.

Other PQRI changes include:

• Reducing the reporting sample requirements for claims- based reporting of individual measures from 80 percent to 50 percent. This could make a difference to anesthesiologists and CRNAs who find it difficult to report the applicable PQRI measures in at least 80 percent of their eligible cases. For example, an anesthesiologist might report Measure #30, timely administration of prophylactic antibiotics in 99 percent of her eligible anesthetics throughout 2010, and Measure #76, prevention of catheter-related bloodstream infections: central venous catheter (CVC) insertion protocol in all 15 of her catheter insertions following an April systems upgrade that facilitated reporting the CVC protocol. Our hypothetical anesthesiologist forgot about the 5 CVCs she had placed during the first three months, however. She would thus have reported the PQRI measure on 15/20 eligible claims, which would give her a 75 percent compliance rate and rob her of her entire PQRI bonus for the year. (By reporting Measure #76 15 times, she declared the CVC protocol applicable to her practice. Under the Measure Applicability Validation process, she would have had to report both Measure #76 and Measure #30 in at least 80 percent of eligible cases to qualify for the bonus.). The 75 percent compliance rate would entitle the anesthesiologist in this example to the bonus in 2011, however.
• Allowing physicians to qualify for an additional 0.5 percent incentive if they satisfactorily report PQRI measures and participate in a Maintenance of Certification program required for board certification by a recognized physician specialty organization [such as the American Board of Anesthesiology] for at least one year and complete a practice assessment as part of that organization’s Maintenance of Certification program
• Establishing the framework for a new Physician Compare website (currently the names of physicians who successfully participate in the 2010 and 2011 PQRI programs will be published on the PQRI web site); 
• Creating an informal review process for providers who wish to have CMS review its determination that a provider has not submitted data for PQRI satisfactorily, by January 1, 2011; and 
• Providing timely, written feedback reports to physicians about satisfactory PQRI reporting, including proposals for interim feedback reports.

The interim feedback reports and review mechanism have been proposed as a result of physician organizations’ including MGMA’s urging that for the PQRI to improve actual patient care, the program must give more timely and actionable clinical information to physicians. This is all the more important because CMS noted, in its discussion of the proposed rule, that only about half of all physicians who participated in the PQRI via claims-based reporting qualified for the incentive bonus.

Please remember that what CMS has just published is its proposed  rule for 2011 physician payment. The final rule, which may be substantially different, although it cannot introduce new topics, is required by law to be published before December. We will provide further information on both the PQRI and the fee schedule rule as it develops in the continuing hope of making it easier for every reader to obtain the payments to which he or she is entitled.

Sincerely,

Tony Mira
President and CEO