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The American Society of Anesthesiologists is an educational, research and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.


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February 1, 2014 Volume 78, Number 2
PQRS: At the Intersection of Quality Improvement and Consumerism Lee A. Fleisher, M.D.,
Committee on Performance and Outcomes Measurement

Daniel J. Cole, M.D., ASA First Vice President

“What gets measured gets done” is an all-too-familiar doctrine in Washington among health policy experts in their quest to leverage payment to quality improvement. The Physician Quality Reporting System (PQRS) is a program developed in 2007 and administered by the Centers for Medicare & Medicaid Services (CMS) to promote reporting of a defined set of quality measures through payment incentives and payment adjustments for eligible professionals. Currently, it provides an incentive payment to the participant for services provided to Medicare Part B fee-for-service beneficiaries. Beginning in 2015, PQRS will include a 1.5 percent payment adjustment (reduction in payment) for those who do not report (with a scheduled reduction of 2.0 percent in 2016). The PQRS submission can be on individual claims, through an approved registry, directly to CMS via a qualified electronic health record, or to a qualified Physician Quality Reporting electronic health record. Alternatively, group practices may participate through the Group Practice Reporting Option. ASA was proactive in developing an approved PQRS registry – the National Anesthesia Clinical Outcomes Registry (NACOR) – that is maintained by the Anesthesia Quality Institute (AQI). NACOR currently contains more than 14 million cases, and participation is free to ASA members.

Originally termed the Physician Quality Reporting Initiative when the PQRS program was developed, it was important to have at least three measures per specialty. The process of developing approved measures included initial endorsement by the American Medical Association (AMA)-Physician Consortium for Performance Improvement (PCPI), followed by submission to the National Quality Forum (NQF) for endorsement, and eventual acceptance by CMS. For anesthesiologists, the proposed performance measures were developed by the Committee on Performance and Outcomes Measurement (CPOM) and required approval of the House of Delegates. Initial measures included antibiotic timing, temperature management and central line insertion management.

According to CMS, in 2011, anesthesiology had the second highest participation rate in PQRS among all specialties at 53.7 percent. This is in large part due to the linkage with the hospital-based Surgical Care Improvement Project measures. PQRS now consists of more than 200 measures, with only three directly applicable to anesthesiology. Despite having three active measures, CPOM and the ASA leadership were concerned that CMS may require new measures as the approved ones became “tapped out,” i.e., compliance was near 100 percent. Additional measures have been developed by CPOM and endorsed by ASA, but they all focus on processes of care rather than true outcomes.

So, despite being in compliance with the current program requirements, are we in good shape for the future? In fact, there are changes on the horizon that threaten the status quo, but fortunately CPOM and ASA leadership have been proactive in communicating and working with CMS on behalf of our members.

Without doubt, there are significant limitations in the application of performance measures and their linkage to payment. Our specialty has been a leader in recognizing these limitations but, frankly, has been slow to adapt to this inevitable reality. One meaningful limitation of performance measures includes the reality that a single measure only assesses a snapshot of a very limited domain of a physician’s practice and falls short of assessing core competencies of a physician that are required for high-quality patient care. A second limitation would be the current science of risk adjusting for a physician’s case mix, which could be obtained from billing as opposed to clinical data, and therefore realizing a potential perverse incentive affecting the care of high-risk patient populations.

Despite these limitations, it is important to recognize that we must be willing to change and accept an increased number of measures that have higher bars in order to meet the new standards and new reality of value-based health care. Specifically, the recently published CMS Physician Fee Schedule Final Rule will require nine measures as opposed to the current three and will require that the measures cover at least three of the National Quality Strategy domains. As noted above, our specialty does not have nine measures available and no clear outcome measure. Importantly, ASA and other groups advocated, and CMS agreed, that eligible professionals who participate in clinical registries and claims-based reporting can continue to report on three measures, subject to the Measures Applicability Validation (MAV) process. But we must be prepared to propose new measures since the current ones must be renewed every three years and may not be re-endorsed by NQF. There has been a transition at NQF and CMS in emphasizing outcome measures as opposed to process measures. One approach is to develop our own outcome measures; and, in fact, temperature management may change from “getting credit” for utilizing forced-air warming to only measuring the intermediate outcome of postanesthesia care unit temperature. Additionally, the practice of anesthesiology is truly integrated within interdisciplinary teams, and there is a paucity of “outcomes” that we exclusively own. Therefore, CPOM has advocated for the use of currently NQF-approved hospital (team)-based outcome measures of 30-day morbidity and mortality surrounding specific surgeries as proposed by the Society of Thoracic Surgeons and the American College of Surgeons. The concept is that patients would benefit from joint accountability between the hospital, surgeons and anesthesiologists for the risk-adjusted outcomes after surgery. NQF is very interested in patient-oriented outcomes such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), and CPOM is evaluating different measures of satisfaction with anesthesia. Maintenance of certification has also been proposed as a PQRS measure.

Finally, the Affordable Care Act required CMS to establish a value-based modifier (VBM) for differential payment to physicians. The VBM will be applied in 2015 to physician groups of 100 or more and to all physicians by 2017. The VBM will be implemented in a budget-neutral manner and will take into account both “quality,” as defined by PQRS measures, and cost. The current proposal would reward physicians who are in the high-quality/low-cost tier and in 2016 would penalize groups who are in the low-quality/high-cost tier by 2.0 percent.

Virtually all parties now agree that the only solution to our current health care problem is focusing on value and the triple aim of better care, healthy people and reduced per-capita cost. While many would argue that value-based purchasing might not be the optimal approach, there is clear evidence that measurement does lead to better outcomes. Moreover, the economic realities of demonstrating that we deliver high-quality care to Medicare patients make a compelling argument that our specialty cannot ignore the realities of PQRS and VBM as we transition to the practice of tomorrow with new payment models. Ensuring that PQRS measures reflect outcomes important to our patients will help us align with the goals of the patients we serve in addition to the goals of the federal government.

Lee A. Fleisher, M.D. is Robert D. Dripps Professor and Chair, Department of Anesthesiology and Critical Care, and Professor of Medicine, Perelman School of Medicine, Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.

Daniel J. Cole, M.D. is Professor of Anesthesiology, Mayo Clinic College of Medicine, Associate Dean, Mayo School of Continuous Professional Development, Vice Dean, Mayo School of Continuous Professional Development, Phoenix.


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