CMS' Physician Quality Reporting Initiative (PQRI): It's a Little Bit (And Taxpayers Are Not Getting Their Money's Worth)

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$234,292,572.02 sure seems like a lot of money, doesn't it?  If you were told that's what the Feds put on the table to promote health care quality among Medicare beneficiaries in 2009, you'd be impressed right?  Too bad for CMS' mandarins that you read the Disease Management Care Blog and know better. 

The DMCB explains.

Background

That $234 million was dispersed under the 2009 edition of the "Physician Quality Reporting Initiative" (or "PQRI")  This was passed into law in 2006 as part of Congress' interest in transitioning Medicare away from pure fee-for-service toward a greater emphasis on "value based purchasing." As the DMCB understands it, physicians submit additional claims codes to Medicare in the course of their routine billing that documents various quality measures.  If enough claims codes are submitted, the provider can get an incentive calculated at - depending on the year -1% to 2% of that year's Medicare payments.  The bonus doesn't depend on the quality, only that the quality was reported to CMS.  That's why it was called a reporting initiative.

PQRI is sill ongoing and participation is completely voluntary. When the program kicked-off in 2007, physicians were given the option of submitting codes in 74 different areas that they could select based on their specialty and interest.  2009 PQRI's 132 measures ranged from diabetes to skin cancer to open heart surgery to management of pain.  You can see the list here.  The 2009 bonus was set at 2%.

How many claims codes did physicians have to report to CMS?   They had four options: 1) at least 3 individual quality-data measurement codes among the 132 measures for at least 80% eligible patients, or 2) all measures in one of the six  "measures group" packages (consisting of "preventive care," "diabetes," "back pain," "chronic kidney disease," "perioperative care," and "rheumatoid arthritis") for at least 80% of eligible patients with a minimum of 30 patients during the period, or 3) the "group" approach, but with a 6-month period of July 1 through December 31, 2009 and a minimum of 15 patients, or 4) the "group" approach for 30 consecutive patients.

The Results

So, what happened?  While the 2007 PQRI kick-off was rocky, the 2009 data have been released and CMS seems quite happy with the program's progress.  Download (and unzip) this report and you'll see the $234 million went to 119,804 "eligible professionals" with an average per physician pay-out of $1,956.  CMS estimates that the percent of Medicare-participating professionals has grown from 15% in 2008 to 20% in 2009. The DMCB calculates that an additional 90,775 providers submitted claims but didn't get the bonus - probably because they incorrectly submitted their data sets. ER physicians led the way with a 62.8% participation rate, while 16.1% and 15.5% of family practice and internal medicine physicians participated, respectively.  These primary care physicians' "average potential incentive" payments were $1,126 and $1,924 respectively.

While the physician bonuses didn't depend on any improvement in measured quality, CMS reported that, for those measures that were in place from '07 to '09, there was a median increase of 1.3% in the quality measures.  Some measures increased dramatically (diabetes eye care, for example by 41 points) while others decreased (beta blockers for MI decreased by 30 points).  That probably has more to do with the influx of new physicians with new data than any real change.

Implications

So, with that as background, what does the DMCB think?

1. While this program isn't exactly "pay for performance" (yet), variations of insurer-sponsored P4P have been in use for years by the majority of U.S. insurers.  It took a (Bush era) law to make that happen and CMS is late to the party.

2.  And the party may be starting to thin out, thanks to better understanding of the limits of P4P, the potential for unintended consequences and growing appreciation that one size doesn't fit all.  If this pay for reporting is a prelude to pay for performance, there doesn't appear to be much in the way of the innovative sophistication that CMS purports to embrace.

3. The DMCB is also struck by CMS' reliance on self-reporting, which is a different approach compared to commercial insurance settings.  In the latter instance, it's up to the insurer to take the time and expense of obtaining the data, even if it means paying individuals to go to the clinics and perform chart reviews.  While CMS' adding an extra claim line in the course of normal billing doesn't seem line an imposition on physician practices, this is one more of a thousand cuts involved in running a clinical practice.

4.  While CMS doesn't touch on this in its reports, the DMCB suspects that the provider groups best positioned to take advantage of this are larger groups with the infrastructure that can take on the additional reporting task.  As a result, the PQRI payments probably went to the larger clinics and therefore probably functionally discriminates against small provider-owned practices.  That may be further evidence of CMS' policy preference that small individual physician practices should go away and become "integrated" in "systems."   As further irony, the DMCB doubts the payments that were awarded to the large clinics went to the individual physician's pockets.

5. Um, "return on investment?"  Are self-reported data from a self-selected group of physicians of any use in truly assessing national quality trends and is that worth $234 million?  Is it even worth the amount we are paying to the Chinese in interest?  Will this lead to $234 million in reduced claims expense to the benefit of the U.S. taxpayer? 'Nuff said.

6. And finally, while close to $2000 may seem like a lot of money, it isn't.  While the DMCB's spouse would welcome a check made out to that amount, by the time overhead takes it's toll, any remaining money that percolates down to the physician might be able to cover the weekly staff donut run. 

Every little bit helps, but that's the problem. When put into perspective: this is a little bit.