ADVOCACY

Medicare: Quality

The Patient Protection and Affordable Care Act made participation in Medicare’s Physician Quality Reporting System (PQRS), formerly referred to as PQRI, mandatory beginning in 2015. However, PLEASE NOTE that the Centers for Medicare and Medicaid Services (CMS) recently ruled that providers who are not successfully/satisfactorily participating in PQRS by the 2013 reporting period (Jan. 1 – Dec. 31, 2013) and beyond, will have their Medicare reimbursement decreased by 1.5 percent beginning in 2015. In 2016, the payment decrease will be 2%.

If you have never participated in PQRS, you may not know where to begin. For those doctors of chiropractic who are continuing their participation in PQRS in 2013, please be advised that significant updates and revisions have been made to the PQRS Measures applicable to chiropractic practices. For more information, and to get started, review the resources below.

Introduction

“Quality” is an increasing concern for healthcare policymakers in Washington, DC. The word dovetails into various areas such as pay-for-performance and health IT. Although this issue and its related areas have been percolating for almost a dozen years (and there is some experience in private pay on the issues), with the development of actual quality measures and the continuing significant reimbursement reform challenges, this is all now on the front-burner where public programs (and specifically, Medicare) are concerned. The Tax Relief and Healthcare Act of 2006 linked reimbursement to reporting on quality measures for the first time; CMS’ Physician Quality Reporting System (PQRS), is the program associated with this.

The Basics: What is a Quality Measure?

Quality measures, generally, are rooted in evidence-based medicine. They can be “guideline” measures (e.g., you get 12 visits for acute low back pain), “process” measures (e.g., when a patient comes in with a cardiovascular episode and you gave them an aspirin), or “outcome” measures (e.g., "X" condition was resolved). There are also other types of measures, such as “structural,” “efficiency,” or “cost of care” measures.

A few points which are important to keep in mind:

There is significant debate on the value of the different types of measures, with the community currently focusing mostly on “process” measures. [Note: “Guideline” measures have generally been discounted as a way to measure quality of care.] Certain groups are also paying close attention to “structural” and “cost of care” measures. The ultimate goal of all parties is to have effective outcomes measures.
There is also significant debate about whether certain measures simply demonstrate competency or actually will improve quality. For example, some measures deal with the documentation of care. Many in the community argue that documentation of care should be happening anyway, while others point out that it doesn’t happen 100% of the time, hence there’s room for improvement—a gap in care—with which a measure could help.
Measures are not specialty-specific.

What Can Individual DCs Do to Prepare?

Understand the PQRS program and report on the measures.

History

Feedback Reports

To access Your 2011 Feedback Report, log on to the secure PQRS Portal on QualityNet