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The Physician Quality Reporting Initiative

The Good, the Bad, and the Ugly

AVITZUR, ORLY, MD

doi: 10.1097/01.NT.0000338403.33460.2a
IN PRACTICE

Dr. Avitzur, a neurologist in private practice in Tarrytown, NY, holds academic appointments at Yale University School of Medicine and New York Medical College. She is also the editor-in-chief of the AAN Web site, AAN.com, and chair of the AAN Practice Management and Technology Subcommittee.

When the Physician Quality Reporting Initiative (PQRI) was launched last year, the voluntary pay-for-reporting program offered the promise of a potential 1.5 percent bonus for successful reporting of adherence to performance measures for Medicare Part B claims effective July 1, 2007, through December 31, 2007.

Performance measures could include these among other actions, for example: Did you discuss prevention of falls? Did you discuss advance directives?

Neurologist Michael J. Kitchell, MD, president-elect of the Iowa Medical Society, was an enthusiastic participant. As chair of the American Medical Association Advisory Committee on Group Practice, he attended the Physician Consortium for Practice Improvement, which worked with the Centers for Medicare and Medicaid Services (CMS) to develop the 74 PQRI measures.

“I believed in the project because I understood how important it was for physicians to document thoroughly in order to demonstrate quality,” he said. Consequently, as president of the board of the McFarland Clinic, a large multi-specialty group in Ames, IA, Dr. Kitchell worked for months with the business office to get ready.

They prepared customized checklists for each of the specialists, tailored reference cards for encounters, created stickers for charge cards, and re-engineered their computer system with special claim-scrubbing software designed to flag errors. Dr. Kitchell led educational programs and implored his group members to sign up. Last month, when the clinic received a 706-page report from CMS on their PQRI results, it took the business office some time to decipher the data, but he finally got the news: he had failed!

In fact, only 56,700 physicians and other eligible professionals had succeeded in meeting the 80 percent completion requirements for satisfactory reporting; according to CMS, the average incentive check was about $600 for individual professionals.

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HIGH FAILURE RATE, ADMINISTRATIVE HURDLES

“It's disturbing,” said Dr. Kitchell. “Because only 16 percent of the nation's [700,000 Medicare-practicing] physicians participated in the program, it means just 8 percent of the nation's physicians succeeded.”

Congress is hoping that PQRI will differentiate between good and bad physicians, Dr. Kitchell added, but with such a high failure rate, and so many administrative hurdles, he is certain that many physicians will drop out.

Indeed, Raleigh Neurology Associates, a North Carolina group of 12 adult neurologists and five pediatric neurologists has done just that. “Our group dived into PQRI with good intentions and with good faith,” recalled S. Mitchell Freedman, MD. The practice modified its encounter forms to include the PQRI parameters so that their physicians and nurses would ask the patients all the proper questions and instructed the physician's assistants who worked in the hospitals how to complete the forms so that when they submitted the bills they would be in compliance.

“When the time came to get the results, you would think we were knocking on the doors of Fort Knox,” Dr. Freedman exclaimed. His office manager made at least a dozen phone calls and was repeatedly misdirected about how to attain the proper code to allow her access to their results.

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After several persistent phone calls, CMS sent an 18-page user guide to enable them to find out how they fared as a group, but it took several days to decipher the directions. The group ultimately received $15,000 (an average of almost $900 per doctor for the six months of work), but deeply regrets the experience.

“The amount of paperwork to accomplish this task was simply mind boggling, and the stumbling blocks that CMS placed in front of the neurologists to get the PQRI data are astonishing” said Dr. Freedman. “Why would anyone want this system to continue as it is? Our time is much more valuable than that.”

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AAN INVOLVEMENT

The AAN also devoted considerable time and resources to helping members understand PQRI. Of 74 PQRI measures, the AAN identified 12 measures that would be of help to neurologists: six inpatient stroke measures (three admission and three discharge), two neuroimaging in stroke/rehabilitation, medication reconciliation, screening for future fall risk, and a measure for the advanced care plan.

James C. Stevens, MD, chair of the AAN Practice Committee, gave multiple presentations, taped podcasts, and was among a cadre of volunteers and staff who helped create educational materials. He also spearheaded the initiative among his own group of neurologists in Fort Wayne, IN, and nine out of ten participated in the initiative.

But even Dr. Stevens concedes that the process was hardly easy. His staff struggled to make sense of their 160-page CMS report and to manually tabulate the physician National Provider Identification numbers that identified participating physicians. The practice ultimately received $15,500 in remuneration (with eight of the nine neurologists succeeding at an average of $1,722 per physician for the entire group).

But the feedback from neurologists has been sobering. “Just because our group got paid does not mean it's a good program,” Dr. Stevens reflected. “CMS had a poor signup rate in the first place, even half of those who had been true believers failed, and those who succeeded were, at best, frustrated by the effort it took to gain access to the report.”

Ironically, in its current iteration PQRI only measures reporting. So while those interviewed struggled in earnest with the more complex stroke codes, a neurologist could hypothetically select “no” (not discussed with patient) to three of the simplest measures — advanced directive, falls, and medication reconciliation — set the code to default to the negative response, and receive a bonus. It would be bad medicine, but successful PQRI.

AAN President Stephen Sergay, MD, signed up for PQRI, along with the rest of his five-member Tampa neurology practice. To their surprise, all five neurologists in his group performed poorly.

“It first took us hours and hours to make sense of the report, and it is now becoming clear that will be impossible to find out why we did not do well enough,” said Dr. Sergay. “As an organization we have to ask ourselves three things about this initiative: Can we do our part, can CMS do their part, and does it add value?”

“I'm not sure we did it right, I suspect that they aren't doing it right, and that it does not add value,” he reflected.” Dr. Sergay is also concerned that the lack of feedback is a critical flaw in the process. “It's missing the educational arm; not only is there no feedback as to why you fail, it's impossible to reach the right person who can answer that question, and the data may not be available,” he said.

“I believe that CMS has reason to be seriously concerned,” Dr. Stevens said, “and the AAN needs to ask itself if this is doable, and if, at the end of the day, it is really going to affect the outcome of patients.”

But Dr. Stevens said it's important to point out that CMS and Congress have committed time and resources to continue the project in 2009. In fact, they have already implemented payment to hospitals directly linked to performance — not just reporting — on certain quality measures. “By keeping involved with the project we have an opportunity to provide feedback to CMS concerning frustrations with the program and suggestions for meaningful improvement,” he advised.

In the meantime, some neurologists have yet to figure out how to get their reports. Elaine C. Jones, MD, member of the AAN Legislative Affairs Committee, received neither check nor report. She tried to log onto the Web site, but spent hours getting registered and then had to wait for the mailed secret code. Now she is unable to get back in to use the code.

Dr. Kitchell anticipates that he will fail again in 2008 (the reporting for this year is more than two thirds completed). “I've been slogging away at it, and I'll probably never know why I failed,” he said. He prefers to cut his losses now rather than try to work through the bureaucratic morass imposed by CMS in order to try to figure out the reasons for his failure.

Although the McFarland Clinic did receive a check of about $67,000 for a number of their 150 physicians who signed up (averaging $447 per participating physician), this was a drop in the bucket compared to costs incurred for implementing the program, said Dr. Kitchell. “I had been a true believer in demonstrating quality and showing that we give the right treatment at the right time, but this experience has been a total disappointment.” Nevertheless, he is not giving up entirely. He is still weighing his options for 2009.

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What One Practice May Have Done Right

AAN Practice Committee Chair James C. Stevens, MD, shared what his group may have done right in their reporting efforts:

  • They kept it simple: low-tech and low-budget.
  • They streamlined the process by creating a one-page form to submit with the demographic sheet.
  • They provided an in-service for administrative staff, providers, and rounding nurses on how to use the form.
  • They chose the three stroke measures that were already an integral part of their practice's stroke protocol and the “get with the guidelines” familiar to neurologists.
  • They assigned vigilant billers to manually cross-check pre-specified ICD-9 (diagnostic codes) for relevant PQRI information.
  • They held those claims that were missing items until physicians complied with requests for information.
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Recruitment Challenges? We Want To Tell Your Story

Unable to retire because you can't find your replacement? If so, we'd like to hear from you for an upcoming story on recruitment challenges, Contact Dr. Orly Avitzur at oavitzur@earthlink.net.

© 2008 American Academy of Neurology