The Physician Quality Reporting Initiative: What Can Emergency Physicians Expect?

A wealth of PQRI-related information, including a list of frequently asked questions, is available at www.cms.hhs.gov/pqri.

ACEP News
April 2007

By Christie L. Carter
ACEP News Contributing Writer

In her role at the Special Program Office, Value Based Purchasing at the Centers for Medicare & Medicaid Services, Susan Nedza, M.D., M.B.A., co-leads education and outreach activities in support of the Physician Quality Reporting Initiative (PQRI). She also serves as the chief medical officer for Region V of CMS. ACEP News recently spoke with Dr. Nedza about PQRI and what it means for emergency physicians.

"Medicare is committed to paying for high-quality, efficient care, and is actively changing the payment system for physicians and hospitals," says Dr. Nedza. "PQRI is the first step in our journey to reward physicians for the high-quality care they provide."

In an interview with ACEP News, Dr. Nedza offered answers to some of emergency physicians’ most common questions about PQRI.

ACEP News: First of all, where are the emergency medicine quality measures currently in the approval process?
Dr. Nedza: Measures are not specialty-specific in PQRI. One of the biggest confusion points for emergency medicine is that physicians think there are measures specifically for them. Emergency physicians should review the final PQRI 2007 74-measure set at www.cms.hhs.gov/pqri and determine which ones make the most sense for the patients they care for and their practice. They can begin to plan for participation now - they don’t have to wait for final specifications. Emergency physicians should select at least three measures on which to submit data. CMS is encouraging physicians to submit data on as many measures as possible to increase their ability to successfully meet the 80% threshold for payment.

ACEP News: What are the next steps in the approval process, and when will emergency physicians have final resolution on the quality measures for 2008?
Dr. Nedza: The measures for 2007 are final. For 2008 and beyond, measures are continually being developed through groups such as the Physician Consortium on Performance Improvement. Many of these groups are involved in developing measures related to conditions that are prevalent in EM practice, and ACEP should continue to participate in measure development activities across specialties. For 2008, all measures that will be added to PQRI must be developed through a consensus-based process, include both measures that have been submitted by a physician specialty and structural measures such as the use of electronic health records or electronic prescribing technology, and be adopted or endorsed by a consensus organization.

ACEP News: Many emergency physicians would like a more detailed understanding of the operational aspect of reporting the measures. Has it been determined how emergency physicians will report on the measures and what codes will be used?
Dr. Nedza: The quality data codes will be reported concurrently with the service via the billing process. CMS will be working with ACEP and with EM groups on education and implementation of the program. Detailed information will also be available through carriers/MACs. Emergency physicians will make the decision regarding which quality data codes to report.

ACEP News: PQRI is currently a voluntary effort, but all signs point to physician reporting of quality measures likely becoming mandatory in the future. Can you give us some idea of CMS’ future plans for these quality measures?
Dr. Nedza: There are no plans to make PQRI mandatory. However, emergency medical care is currently being measured through the Hospital Compare program, which is being expanded to include measures of surgical quality, 30-day mortality and patient experience of care. CMS is currently developing a strategic pay-for-performance plan for hospitals that would begin in 2009. It is important that EM physicians and their groups have strategies and mechanisms in place to support hospitals’ efforts to improve quality.

ACEP News: What can you tell us about the bonus payment for emergency physicians who successfully report a designated set of quality measures in 2007?
Dr. Nedza: Emergency physicians and other eligible professionals who successfully report as prescribed by TRHCA section 101 may earn a 1.5% bonus, subject to cap. The potential 1.5% bonus will be based on allowed charges for covered professional services: (1) furnished during the reporting period of July 1 through Dec. 31, 2007 for beneficiaries in the traditional Medicare fee-for-service program, (2) received into the CMS National Claims History (NCH) file by Feb. 29, 2008, and (3) paid under the Medicare Physician Fee Schedule. I recommend that physicians review their billings for the same time period in 2006 (last two quarters) and multiple the number by 1.5% to get a sense of the potential bonus incentive payment.

ACEP News: In your opinion, will the modest income gain offset the administrative costs to report these quality measures?
Dr. Nedza: The program offers emergency physicians an opportunity to improve clinical care and to support data collection and submission of quality data to a potentially broader audience, including private payers, consumers, ABEM and states. It may also allow for groups to reward physicians for quality care - not just for throughput or RVUs. 

ACEP News: Overall, why should emergency physicians welcome these quality measures?
Dr. Nedza: ACEP’s core mission is to support quality emergency care, as well as to support efforts to ensure that emergency physicians have the resources available and the ability to provide quality care to those who seek it. PQRI links financial incentives to the provision of quality care, and it provides the opportunity for emergency physicians to work with hospitals to improve patient flow, access to necessary specialty and clinical services, and resources necessary to provide high-quality care. 

PQRI represents an opportunity for emergency medicine to utilize its expertise, to commit to research related to quality and efficiency, and to advocate for payment for what is at the core of emergency medicine - high-quality care. Not taking advantage of this opportunity could leave emergency medicine with little data to validate its value within the continuum of care. Because payment is linked to quality and efficiency, the rewards in the system may be claimed by others.

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