While Medicare’s incentive initiative is expanding, it remains controversial. Some experts see it as an opportunity for a "dress rehearsal" for the days when reporting will be mandatory and the stakes much higher.

Still in its infancy, the Physician Quality Reporting Initiative (PQRI) is the Centers for Medicare and Medicaid Services’ first nationwide initiative to provide incentives to encourage the reporting of quality data by physicians and other health care professionals, including nonphysician practitioners and certain types of therapists. It was initially authorized by the Tax Relief and Health Care Act of 2006, which required CMS to establish a quality data-reporting system and to pay an incentive to eligible health care professionals for satisfactorily reporting data on quality measures relating to the care delivered to Medicare beneficiaries.

CMS launched this voluntary initiative in 2007 and collected quality information for services furnished from July 1, 2007, through December 31, 2007. As a result of the 2007 PQRI data collection effort, CMS paid $36 million in incentive payments to health care professionals who met the criteria for satisfactorily reporting data during the 2007 PQRI. These incentive payments were sent out starting in July 2008. So far, the average individual eligible professional incentive amount is more than $630. The largest incentive payment for a group practice is $205,795 (a group practice is comprised of several satisfactorily reporting eligible professionals), and the average incentive is $4,713. This is a result of the CMS requirement to pay eligible professionals (and groups under the same tax ID) who satisfactorily report measures an incentive payment equal to 1.5% of their allowed charges for covered services during the specified reporting period. To be eligible for an incentive payment, health care professionals are generally obligated to report at least three quality measures for at least 80% of the cases in which the measure was applicable.

In the first submission period in 2007, a total of 74 measures were available for reporting with three measures pertaining to radiology—two focused on diagnostic radiology and one on radiation oncology. The measures were developed by an AMA multidisciplinary work group specifically for PQRI. In 2008, the number of measures was increased to 119. Eight new measures pertained to radiology. A total of 175 measures are proposed for 2009, and the bonus payment is slated to increase from 1.5% to 2%. It is not certain how many new radiology measures will be included in the 2009 plans, but seven new ones and one revision have been proposed.

Nationally, 109,349 professionals and practices attempted to participate in the 2007 PQRI data collection effort. A total of 56,722 eligible professionals satisfactorily reported and completed the program and were eligible for an incentive payment. On average, professionals and practices that attempted to send CMS data sent at least three measures. This means that only 48% of those who contributed data were actually eligible for incentive rewards. This overall rate of successful reporting was similar for radiologists. Considering the $150 million budget, that means there were lots of potential payments left on the table by physicians.

According to Sheri Poe Bernard, CPC, CPC-H, CPC-P, vice president of member relations at the American Academy of Professional Coders based in Salt Lake City, "PQRI is a Medicare program to reward physicians who practice preventive medicine regularly. Preventive medicine, by its nature, reduces the cost of health care and improves outcomes for patients. Examples of PQRI targets affecting imaging include LVF assessment in a patient with heart failure; DXA screening for female patients 65 years or older; or neck MRAs or CTAs performed for patients with ischemic stroke or TIA."

Lack of Enthusiasm Evident

But so far there is a disturbing lack of enthusiasm for the program. Poe Bernard said, "Clearly, anything that improves patient outcomes should be considered a pro, and rewarding physicians for preventive care is also a good thing. Unfortunately, the CPT codes used for PQRI are somewhat cumbersome. More importantly, reporting systems that don’t have the benefit of an EMR with practice management integration will be at a disadvantage because the reporting, when done manually, can be very tedious."

Jay A. Gold, MD, JD, MPH, senior vice president and chief medical officer of MetaStar Inc, of Madison, Wis, said, "CMS says that PQRI is a first step toward linking Medicare health professionals’ payments to quality, per Medicare’s intended transformation from passive payor to active purchaser of high-value health care. PQRI measures are based on evidence-based clinical guidelines, so if the data are used for performance improvement, the program will improve patient care. Participating in PQRI is a way to prepare for future pay-for-performance (P4P) programs. Also, there are plans for feedback reports that compare the data from a physician’s practice with those for other practices, which can be used for benchmarking." However, he lamented, "The reporting takes time, especially for practices without EHRs and even those with them. The incentive can be small compared with the expenditure of effort, and sometimes does not cover the resources used to report."

Paul Larson, MD, a practicing radiologist in Oshkosh, Wis, who serves on the American College of Radiology steering committee, is concerned about the lack of interest among physicians in enrolling in the program. "Sixteen percent to 17% of all doctors are participating, with about the same percentage for radiologists," he said. "A lot of doctors don’t know the program exists, and some doctors are suspicious or don’t quite understand the program. Others simply don’t want to be compared and don’t like to share data." It is likely that less than 10% of radiology practices received a 2007 PQRI bonus payment.

"What they [CMS] do with the data is a question. Doctors would like to have feedback quicker on results, that is, saying why they did or did not succeed," said Larson. Poe Bernard concurred, "Few are enrolled because reporting is tedious, and it isn’t required. The ‘carrot’ provided to participants in PQRI isn’t very big; it’s hardly worth the effort. The real benefit of participating is this: pay for performance is going to become a fact of life in American medicine, and PQRI gives physicians the opportunity to be paid for a ‘dress rehearsal’ for the days when reporting is mandatory and the stakes are higher."

According to Poe Bernard, "Physician office managers are saying the checks they anticipated for participation are only a fraction of the amount they expected. However, some of the private P4P programs already under way in California and other parts of the country are providing significant benefits to physicians. PQRI is still in its infancy, and will likely improve." She also noted, "Remember that the reimbursement for PQRI is based on total Medicare allowed claims, not just the billings associated with the measures. In this respect, PQRI may actually favor radiologists, since by virtue of the PQRI targets, radiologists’ reporting would be minimal."

The other PQRI failings reported include rewarding volume of services over quality of care and failure to focus on prevention and coordination of care for beneficiaries. In addition, the current system has led to a rapid growth in Medicare spending without evidence that the spending is leading to better quality care.

Will PQRI become mandatory? Poe Bernard said the answer is yes, "Mandatory for Medicare and also some form of P4P adopted by individual payors. And the stakes will be raised. The sooner a physician gets on board and begins reporting for PQRI, the less revenue will be at risk in the future."

Gold added, "CMS remains interested in what it calls ‘value-based purchasing.’ They need data in order to determine value. So it’s a fair bet that PQRI or something like it will become more widespread and more established. If I had to bet, I would bet that despite the political obstacles, at some point it will be mandatory."

In terms of specific advantages for radiologists, Gold said that "the one advantage I can think of is that since so many radiologists work exclusively for hospitals, and so many hospitals have or are acquiring EHRs, tabulating and aggregating the data may be somewhat easier in radiology than in other specialties."

P4P in the Future?

Although the current program is not P4P, Larson agreed that "down the line, PQRI will become a P4P proposition," although he is uncertain whether it will become strictly mandatory. "PQRI is now about reporting, but the ultimate goal is performance." Essentially, everyone wins with the current version of PQRI because performance outcomes are not relevant to the procedure. The health care provider gets the same payment for reporting a "failure" or "success." In contrast, P4P will mean winners and losers. Payment will be for "success" only, and perhaps a level of success.

"P4P implies increased payment for highest performers but also may indicate decreased payment for lowest performers," Larson said. The physician’s ideal would put new money into the system for high performers with no change in payment for others. The payor’s ideal would give high performers the going rate, while others get lower payment. However, a realistic scenario would keep total money unchanged, giving highest performers increased payment and lowest performers decreased payment with most receiving no change in payment. All this, however, has yet to be established.

Larson noted that P4P within PQRI, however it is configured, can have unintended consequences. For instance, "A given measure may reflect only a portion of overall quality of care. It could be possible to satisfy the measure but decrease overall quality." Imaging results are often several steps removed from ultimate patient outcomes. Can health care providers accurately determine the contribution of imaging to ultimate outcomes? A perplexing example is mammography screening in cancer detection.

Lower call-back rates with an equivalent detection rate are desirable. But what is the appropriate tradeoff of increased call-backs to achieve increased cancer detection? Should CMS compensate for decreased callback without ensuring maintenance of the cancer detection rate? This might require more complex measures, or the topic may not be appropriate at all for P4P.

"Outcomes can be dependent on multiple physicians, and as measures mature and become more complex, they may need to overlap specialty lines, which would mean reporting would be more complex," said Larson. At any rate, P4P measures require significant distribution of performance to work. According to Larson, measures should be reasonably attainable in all settings and measures should promote quality improvement. As overall quality improves, distribution of performance will decrease and prescribed measures will not work in a P4P structure. Measures will need to evolve or be retired, and new measures will be needed continually.

Initial reporting for the current program was on a case-by-case basis with coding and tracking required. An alternative may be through a registry. CMS will soon approve registries. And others are developing multiple registries. Outcomes will depend on multiple physicians with aggregate data reported to CMS by the registry at less frequent intervals.

"CMS is feeling their own way," Larson said. "I’m not entirely pleased with the program, but in the long run I expect positive results."

James Markland is a contributing writer for Axis Imaging News. For more information, contact .