Published in the July 2008 issue of Today’s Hospitalist
LATER THIS MONTH, almost 100,000 physicians should receive their first bonus for reporting on performance measures in 2007 for their Medicare patients. The question now is how physicians “particularly hospitalists “will fare in this first bonus round. Will they actually get the full bonus amount? And how many more physicians will participate in the program this year and in years to come?
It was just one year ago that Medicare opened up its pay-for-reporting program, the Physician Quality Reporting Initiative (PQRI), to physicians who treat Medicare patients. The rules are fairly simple: Report data for at least three Medicare performance measures on at least 80% of all patients covered by those measures. You’ll get a bonus of 1.5% of your total allowable Medicare charges between July 1 and Dec. 31, 2007, the six months the program was in effect last year.
Despite the lure of a bonus, physician reception of the program was mixed. Less than 20% of eligible physicians participated in PQRI last year, which is now in full swing for the 2008 calendar year.
Patrick Torcson, MD, acknowledges that the program has some kinks that need to be ironed out. It would have been nice, for example, to get feedback sooner, he says. But from his perspective, the program has been a success. As a hospitalist program director and chair of the performance and standards committee for the Society of Hospital Medicine (SHM), he urges all hospitalists to embrace the 11 PQRI measures that apply to hospital medicine and to start collecting and reporting data now.
That’s particularly important, he says, because several new elements of the 2009 version of PQRI may make it more important than ever to get involved.
Enough money on the table?
Along with bonus payments, the Centers for Medicare and Medicaid Services plans to provide a confidential, individualized performance report online for physicians who participated in the program last year.
As for spotty physician participation, here’s one question that’s often raised: Is the 1.5% bonus enough to encourage physicians to report?
As Dr. Torcson is quick to explain, 1.5% of a hospitalist’s Medicare billings isn’t exactly pocket change. According to SHM estimates, he says, hospitalists participating in the program can expect to receive an average bonus for a full year of reporting of about $2,000. For 2009, he adds, PQRI bonuses are expected to hit 2%, depending on what happens to legislation currently before Congress.
Dr. Torcson also points out that the real incentive is preparing for a future in which physicians are financially rewarded “or penalized “for how well they meet performance measures.
“Right now it’s just pay for reporting,” he explains, “but soon it’s going to be pay for performance. Now is the time to fail, before we start seeing substantial bonuses and payment differentials, including takeaways.”
While many physicians worry that reporting will be too burdensome, Dr. Torcson says that programs like PQRI are a natural for hospitalists. “We practice in a highly measured environment, with core measures and hospital-level performance reporting,” he says. “This really is part of the job description of a hospitalist.”
A bundling strategy
At St. Tammany Hospital in Covington, La., where Dr. Torcson is director of hospital medicine, the hospitalist group reported on all 11 applicable measures. The group uses an electronic billing system, so the documentation and special CPT II codes necessary to participate in PQRI can be entered during physicians’ regular work routine.
To be more efficient, the group integrated measure reporting into its admissions and discharge process. Five measures can be reported during admission, while the other six can be reported during discharge.
“Our reporting strategy has been to bundle the measures and do the reporting at those times,” Dr. Torcson says. “It’s a hospital-specific strategy for PQRI.”
He explains that some measures have definitely improved care. One example is the PQRI advance care plan measure, which calls for physicians to ask all patients if they have a living will or a surrogate decision-maker.
“It avoids futile care for terminally ill patients,” Dr. Torcson says, “and it helps reduce the unnecessary use of resources. Patients eligible for hospice are getting earlier referrals.”
Dr. Torcson admits that reporting on the advanced care measure is relatively easy because it applies to all Medicare patients, and physicians merely need to ask a question and document the response. Other aspects of the program, he says, are more challenging.
For instance, the program requires physicians to use special CPT II codes that apply to only a handful of disease states, and only for patients covered by Medicare. (Commercial insurers aren’t using CPT II codes yet.) “It’s not all patients,” Dr. Torcson says, “and not even all patients with a condition like heart failure.”
Then there’s the issue of secondary diagnoses, which count toward PQRI’s reporting requirements. If a patient with diabetes also has coronary artery disease (CAD), it’s easy to overlook that secondary diagnosis “even though that patient would count toward your bonus if you’re reporting on CAD measures.
Hospitalists who have to review each measure manually for every patient will have problems. “By the time you reach 11 measures,” Dr. Torcson says, “there are going to be human errors that result in a failure to successfully report. From what we’ve seen, groups are going to need an electronic decision support system to make this effective.”
A work in progress
The best way for hospitalists to prepare themselves for the growing pay-for-performance movement “and to have some input into program design “is to participate now. Dr. Torcson explains that when PQRI measures were first created, only a few applied to hospitalists because Medicare doesn’t recognize hospital medicine as a distinct specialty.
“We were able to change some measures to harmonize with the core measures that we as hospitalists already report,” he points out.
In 2009, hospitalists can expect to see new measures that touch on their unique inpatient role. Those will focus on processes and transitions of care, including medication reconciliation. (Upcoming program innovations that have made headlines, such as the use of electronic medical record data and alternative registries, will be tested in 2009 with only outpatient physicians.)
Even for hospitalists who haven’t filed a single report, Dr. Torcson says that it’s not too late. While physicians who begin reporting now for 2008 may have trouble receiving the full 1.5% yearly bonus, “if you’re trying to develop performance reporting skills for 2009,” says Dr. Torcson, “it’s a good time to get started.”
Edward Doyle is Editor of Today’s Hospitalist.