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PQRS: Health care focus shifts from volume to value

During the last several years, a seismic change has occurred in health care payment and delivery, shifting the focus from volume-based to value-based reimbursement. In value-based care, providers are rewarded for the kind of care they provide, not how much they provide.

The shift began in 2007 when CMS established the Physician Quality Reporting Initiative under the Tax Relief and Health Care Act of 2006. The goal of the program was to improve health care in the United States by collecting and evaluating meaningful quality data.

Now called the Physician Quality Reporting System (PQRS), the program is just one part of a multipronged approach aimed to improving the quality of U.S. health care. The meaningful use electronic health record (EHR) incentive program and the value-based modifier are two other critical components.

“[Secretary of Health and Human Services] Sylvia Burwell has been public about her desire for physician reimbursement to be based on alternative measures, like value-based pricing and value-based reimbursement up to 90% by the year 2018,” John M. Tokish, MD, the education chairman for the Arthroscopy Association of North America, clinical professor at the University of South Carolina School of Medicine – Greenville and associate fellowship director for the Steadman Hawkins Clinic of the Carolinas, said. “I think most surgeons understand that we are going to be graded on what these outcomes are.”

In the early days of PQRS, eligible providers — physicians and physician groups who are paid under the Medicare Physician Fee Schedule — were offered incentives to participate. Providers who successfully reported their quality data to CMS earned up to 1.5% in bonus payments on their Medicare Part B Physician Fee Schedule. In 2008, the incentive was increased to 2% under the Medicare Improvement for Patients and Providers Act.

John M. Tokish, MD

John M. Tokish, MD, the education chairman for the Arthroscopy Association of North America, clinical professor at the University of South Carolina School of Medicine – Greenville and associate fellowship director for the Steadman Hawkins Clinic of the Carolinas, highlighted that the PQRS will start affecting physicians’ bottom line in terms of their Medicare reimbursement rate..

Image: Hawkins Foundation

Despite these incentives, providers have been slow to participate in PQRS. In 2013, 51% of the 1.25 million eligible providers submitted data, according to a press release from CMS.

Some find the program confusing

There are several reasons for the lack of participation. Some providers are unaware of the program while others have shunned it because it is cumbersome.

David C. Ayers, MD, chair of orthopedics at the University of Massachusetts in Worcester, Mass, noted nonparticipation in PQRS for 2013 will lead to a 1.5% penalty for every claim files in 2015, with failure to participate in 2014 and 2015 both resulting in 2% penalties for 2016 and 2017 claims. He highlighted that the impact is cumulative, leading to a potential “penalty of 7.5% on all your Medicare billings” if a physician does not participate from 2013 through 2015, and the 2% withhold remains intact.

David C. Ayers

David C. Ayers

 

“I do not think providers understand the system,” Ayers said. “Many doctors and group practices say the program is confusing and time-consuming and choose not to participate.”