Proposed Changes to the PQRI Program by CMS in its 2011 Proposed Rule

On June 25, 2010, the Centers for Medicare & Medicaid Services (CMS) released the 2011 Physician Fee Schedule proposed rule. There are many initiatives that represent the implementation of the Patient Affordable Care Act (PACA) and the shift to physician payment that is tied to quality outcomes. One important program that is modified in the proposed rule is the Physician Quality Reporting Initiative (PQRI). As part of the modifications to PQRI, CMS proposes to implement several provisions of PPACA that changed the structure and function of the PQRI program

The 2011 Medicare Physician Fee Schedule Proposed Rule, which includes the proposed changes to PQRI, is now on display at the Office of the Federal Register's Public Inspection Desk and will be published in the Federal Register on July 13, 2010. In the interim, it is available for download on the Federal Register website. CMS will accept comments on the proposed rule until August 24, 2010, and will respond to them in a final rule to be issued on or about November 1, 2010.

The Society’s Health Policy Staff will continue to review the impact of these changes on PQRI. Please e-mail Laura Blum, Director, Quality Improvement and Outcomes, if you have any questions.

The Society's analysis of these changes:

Impact on Physician Reimbursement
A significant upcoming change will begin in calendar year 2015 when there will be a penalty for eligible providers who does not satisfactorily report to PQRI. For 2011, physicians may earn an incentive payment of 1.0 percent of their estimated total allowed charges. Also in 2011, physicians who successfully report to PQRI are eligible to earn an additional 0.5 bonus if they participate in a Board Certification Maintenance of Certification program.

Reporting Options
CMS is not proposing to offer additional reporting options for individual physicians. Consistent with the 2010 reporting structure, CMS provides the options for 6-month and12-month reporting periods for claims-based reporting and registry-based reporting and a 12-month reporting period for EHR-based reporting. CMS continues to approve additional registries in an effort to provide sufficient number of registries by 2012 to make it possible to reduce the claims-based reporting mechanism for many measures after 2011. To increase participation and improve the likelihood of receiving a bonus, CMS proposes reducing the reporting sample requirements for claims-based reporting of individual measures from 80 percent to 50 percent.

Group Practice Reporting Option I (GPRO)
CMS proposes a new Group Practice Reporting Option I (GPRO) that would allow group practices with fewer than 200 eligible physicians to participate in PQRI. This program is in addition to the existing group reporting option for groups with 200 or more physicians. The proposed 26 measures for 2011 are based on the Doctor’s Office Quality measures developed as a demonstration project and subsequently used in 2010 PQRI GPRO.  These quality measures are grouped into four disease modules:

• coronary artery disease
• diabetes
• heart failure
• preventive care services

Changes to PQRI Program: Structure and Function
In the proposed rule, CMS discusses changes to the structure and function of the PQRI program for 2011 and subsequent program years. These changes respond to the modifications to the PQRI changes made in the Affordable Care Act and include:

• Extending PQRI incentive payments for years 2012 through 2014 by providing an incentive payment of 0.5 percent the physician’s estimated total allowed charges during the applicable reporting period
• Implementing PQRI payment penalties beginning in 2015 for individual physician and group practices that do not satisfactorily report data on quality measures by reducing the fee schedule payment by 1.5 percent in 2015 and 2.0 percent in 2016 and beyond
• Providing "timely" feedback reports to EPs about their PQRI reporting, including proposals for interim feedback reports
• Creating an "informal" appeal process in which physicians can request that CMS review its determination.
• Establishing the new Physician Compare website by January 1, 2011, on which information on physicians who participate in the PQRI program would be posted. CMS will implement a plan by January 1, 2013, to report 2012 PQRI information on the Physician Compare website

Proposed Additional Measures
For 2011, CMS is retaining 170 measures currently used in the 2010 PQRI including 45 registry-only measures in the 2010 PQRI. As the Society has noted in public comments in previous years, these measures are not optimal to measure heart rhythm care.

For electronic health record reporting, CMS proposes to make a total of 22 measures available for EHR-based reporting including the 10 measures available for EHR-based reporting in the 2010 PQRI and 12 additional measures that overlap with the clinical quality measures used in the EHR incentive program. Similar to the other reporting options in previous years, there are limited performance measures that are optimal to measure heart rhythm care.

Although CMS solicits comments on the proposed 2011 PQRI quality measure set, CMS will not consider measures for 2011 that were not included in this proposed rule. However, the agency will review recommendations for measures for possible use in future years’ PQRI or other pertinent initiatives.The Society will emphasize the importance of including performance measures that are salient to subspecialities.

Integration of PQRI with the Electronic Health Record Incentive Program
CMS will integrate its reporting on quality measures under PQRI with the reporting elements required by the Electronic Health Record Incentive Program (established under a separate regulation). Beginning in 2009, CMS implemented an E-Prescribing Incentive program for eligible physicians who are "successful electronic prescribers" as defined by the Medicare Improvements for Patients & Providers Act (MIPPA) of 2008.

CMS made the following changes and proposed modifications to this program:

• Physicians and group practices who are successful e-prescribers for 2011 may earn an incentive payment of 10 percent of the physicians’ (or group practice’s) estimated total allowed charges during the reporting period
• Beginning in 2012, the program will impose penalties on physicians who are not successful e-prescribers.
• CMS clarified that physicians who are eligible to participate and qualify for the Medicare Electronic Health Records Incentive Program for calendar year 2011, may not receive a separate, additional Medicare eRx Incentive Program payment
• CMS clarified that physicians who receive incentives under the EHR Incentive Program for calendar year 2011 could still be subject to a penalty applicable in 2012 for not participating and being a successful electronic prescribers in the eRx Incentive Program in 2011
• CMS broadens the scope of the eRX Incentive program to group practices with fewer than 200 members to participate in the eRx Incentive Program as group practices
• Establishes criteria for applying the penalty applicable in 2012 or 2013 that eligible physicians (and group practices) may incur if they do not participate successfully in the eRx Incentive Program in 2011 or 2012, including a proposed process for hardship exemptions.

The Heart Rhythm Society will submit public comments on changes to the PQRI system. The Society will also comment on other important reimbursement related issues proposed in the rule. View the 2011 MPFS reimbursement highlights.