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nesthesiologists
who participate in Medicare’s Physician
Quality Reporting Initiative (PQRI) will be eligible
for a 1.5-percent bonus based on the total dollar
amount of their claims submitted to Medicare during
the second half of 2007. This is tantamount to
a 1.5-percent increase in the conversion factors
for both anesthesia and for all other services
for the period July 1 through December 31. To
place the potential bonus in context, consider
that the average annual change in the anesthesia
conversion factor since 1992, the first year in
which the Physician Fee Schedule was implemented,
is a 1.5-percent increase.
This column will discuss the PQRI conditions for
earning the bonus and the origins and significance
of the program. The most important points are:
1. To participate, physicians must begin
reporting the PQRI measures, using specific
codes on their Medicare claim forms, on July
1.
2. Feedback reports are confidential.
3. The program is strictly voluntary. The
only penalty for not reporting is the loss
of the opportunity to earn the bonus.
4. Centers for Medicare & Medicaid Services
(CMS) only published specifications for the
measures in April. ASA members should make
sure that they check www.ASAhq.org,
www.cms.hhs.gov/pqri
and their own carriers’ Web sites frequently
as more PQRI information comes out. |
Eligibility for the Bonus
All physicians and certain allied health professionals
will be eligible to participate in the PQRI, whether
they participate with Medicare or not. No preregistration
is necessary. Submitting one’s first claim
containing PQRI codes will trigger participation.
To earn the bonus, anesthesiologists will report
each measure by submitting the specified quality-data
codes on all Medicare claims to which the measure
applies. As long as the anesthesiologist reports
each applicable measure on at least 80 percent
of the claims for the cases in which that measure
could have been performed and reported, he or
she will qualify for the bonus.
What Are the Applicable Measures?
For the 2007 reporting period, there is only one
measure that is clearly intended for anesthesiologists
(and which would probably not have been included
but for the considerable efforts of Alexander
A. Hannenberg, M.D., Vice-President for Professional
Affairs, and other ASA representatives): the timely
administration of antibiotic prophylaxis to surgical
patients. In order to be part of the initial set
of 74 measures that CMS had adopted for the PQRI
as of January, the antibiotic prophylaxis measure
had to pass muster with the American Medical Association
Physician Consortium for Performance Improvement
and also with the Ambulatory Quality Alliance
(see the December
2006 issue of the ASA NEWSLETTER
for explanations of the role of these organizations).
Although the third major entity whose endorsement
is theoretically necessary, the National Quality
Forum, has not yet approved a physician-level
antibiotic measure, it seems certain that the
PQRI will be receiving data on the measure described
on its official list thus:
30. Perioperative Care: Timing of
Prophylactic Antibiotic — Administering
Physician Description
Percentage of surgical patients aged 18 years
and older who have an order for a parenteral
antibiotic to be given within one hour (if
fluoroquinolone or vancomycin, two hours)
prior to the surgical incision (or start of
procedure when no incision is required) for
whom administration of prophylactic antibiotic
has been initiated within one hour (if fluoroquinolone
or vancomycin, two hours) prior to the surgical
incision (or start of procedure when no incision
is required) |
Many anesthesiologists are assuming the responsibility
for the preoperative administration of beta-blockers
to coronary artery bypass graft (CABG) patients,
and there is also a PQRI measure for this service.
The PQRI list contains a number of other measures
that are so general as to be potentially applicable
to all physicians; for example, screening patients
over age 65 for fall risks.
The whole panoply of measures is important because
physicians must report on at least three measures
80 percent of the time in order to obtain the
bonus, unless fewer than three are applicable.
CMS does not yet have an answer to the question
whether the beta blockade, fall screening or any
other measures are “applicable” to
anesthesiologists. Among the answers to the frequently
asked questions on the PQRI Web site is the following:
The December 2006 Medicare legislation that created
the PQRI, the Tax Relief and Health Care Act of
2006 (TRHCA, pronounced “Trisha”)
“requires CMS to validate, using sampling
or other means, whether quality measures applicable
to covered services of a participating eligible
professional have been reported. We plan to focus
on situations where eligible professionals have
successfully reported fewer than three quality
measures.” A lot will depend on the methods
of sampling and validation.
Mechanics of Reporting
CMS deserves credit for having made reporting
performance of the PQRI measures as simple as
possible. The PQRI grew out of the 2006 Physician
Voluntary Reporting Program under which a small
number of physicians opted to report on a set
of 16 initial measures without a financial incentive.
Both are based on including performance codes
on the claim submitted to Medicare.
Like other performance reporting systems, the
PQRI measures consist of a numerator and a denominator
that permit the calculation of the proportion
of a given patient population that receives a
particular intervention or experiences a particular
outcome over a stated period of time. The PQRI
numerator consists of a new quality process code
adopted by the Current Procedural Terminology
(CPT™) Editorial Panel (“Category
II” codes) or, if there is no CPT-II code,
by CMS (“HCPCS” codes). These codes
all have five digits, consistent with the CPT™
and CMS models.
If the particular intervention is not performed,
anesthesiologists and others should nevertheless
report the appropriate CPT-II and HCPCS codes
on the claim. Remember that the PQRI is about
reporting not about achieving clinical
perfection. Two-digit modifiers appended to the
numerator code allow the physician to report that
the intervention was not performed, i.e., documented,
for either a specific or a “not otherwise
specified” (NOS) reason. Table 1 below displays
the structure of PQRI measures.
 |
The PQRI codes are to be entered on the claim
like any other CPT procedure code, except that
the submitted charge must be “$0.00.”
Attribution — Who Reports and Who Gets Paid?
The individual anesthesiologist who performs the
intervention, i.e., who ensures the timely administration
of prophylactic antibiotics, reports the PQRI
codes (4048F and 4047F) on the claim submitted
under his or her name and National Provider Number
(NPI). CMS will analyze whether the 80-percent
threshold has been met at the individual clinician
level.
Consistent with the primary objective of the PQRI
program, which is to accustom health professionals
to reporting quality and performance measures,
if two clinicians participate in the case and
both report the PQRI measure on their claim, it
will count toward the 80-percent threshold for
each of them. Nurse anesthetists who submit their
claims independently will thus be able to report
applicable measures even if the anesthesiologist
does so, too.
The bonus payment will go to the anesthesiology
group, or to the individual, or even to the hospital
if the hospital employs the anesthesiologist or
nurse anesthetist — whoever holds the Taxpayer
Identification Number (TIN) that is also entered
on the claim. If only one anesthesiologist in
a group using a single TIN qualifies for the bonus,
the group will still receive the payment. It can
then pay the bonus, of course, to the member who
earned it or distribute it in any other manner.
There is a statutory cap on the bonus for physicians
who report low volumes of cases with a PQRI measure.
This cap is unlikely to affect anesthesiologists
because, if they choose to participate, the antibiotic
prophylaxis measure will be reportable in every
surgical procedure for which antibiotics have
been ordered. The purpose of the cap is to prevent
a physician or other health professional from
earning, for example, $3,000 based on total Medicare
allowed charges of $200,000 (1.5 percent) for
reporting a measure on claims filed for as few
as four out of a total of five eligible cases
performed between July 1, 2007, and January 1,
2008.
Confidential Feedback
CMS will give confidential feedback reports to
participating physicians at about the time that
the lump sum bonus payments go out in mid-2008.
There will be no interim feedback and no public
disclosure.
What Happens in 2008?
Congress created a quality reporting program for
2007 when it enacted TRHCA. Without additional
legislation —and funding — it is not
clear whether the PQRI will continue into 2008.
CMS expects to be administering the PQRI or a
similar program next year, however, and TRHCA
does give CMS the discretion to expand measures
to include structural measures such as the use
of electronic health records and electronic prescribing
technology. Proposed measures for 2008 will be
published by August 15, 2007, and finalized by
November 15, 2007. The law directs CMS to consider
the use of medical registry-based reporting.
ASA, in addition to beginning to explore potential
registries for reporting by its members, has brought
four draft measures for anesthesiologists to the
AMA Physician Consortium for Performance Improvement
and is working to ensure the adoption of as many
as possible. See Figure 1 — and watch the
ASA Web site for information on when the Consortium
Web site will be ready to receive your comments.
| Figure 1 |
 |
| Slide by Karin Bierstein
from New Orleans presentation, March 30. |
Conclusion: Is the PQRI Going to Be Important
to Us?
Yes. CMS sees the PQRI as a first step toward
the agency’s transformation “from
a passive payer of claims to an active purchaser
of health care services.” As we already
know, the objective of CMS and other payers is
now “Value-Based Purchasing,”
and “value” depends on ensuring quality,
objectively measured and transparent. Performance
reporting will be the foundation of incentives
and rewards for the improvement and maintenance
of quality.
Finally, is the bonus going to be worth it? Take
a hypothetical 10-anesthesiologist group providing
1,800 Medicare anesthetics from July through December.
Assuming that the average number of cases per
unit is 14, because Medicare cases take longer,
and that the 80-percent threshold is met, the
group will receive a $6,119.82 bonus payment next
summer:
Medicare cases
Average units per case
Total allowed units
National average anesthesia conversion factor
Total allowed charges
PQRI Bonus
Payment |
1,800
14
25,200
$16.19
$ 407,988.00
1.50%
$6,119.82 |
The more significant incentive is undoubtedly
going to be the professional satisfaction of moving
the group’s performance up into the highest
decile. With a national average rate of 77 percent
of surgical patients receiving prophylactic antibiotics
within one hour before incision, according to
hospital data reported to CMS and published at
www.hospitalcompare.hhs.gov,
and the top decile performing at the 95-percent
level, there is room for improvement in many anesthesiology
departments. A study published in the December
issue of Anesthesia & Analgesia (see
Source Material below) shows one hospital’s
successful strategy.
| See page
22 for detailed information
on performance measures and the Physician
Quality Reporting Initiative. |