The goal of this article is to provide background on national quality measure reporting and reimbursement programs as well as updates regarding current, future, and retired quality measures relevant to the practice of emergency medicine.
Explore This IssueACEP News: Vol 31 – No 09 – September 2012
The Centers for Medicare and Medicaid Services (CMS) remains the dominant player in the determination of how hospitals and providers are reimbursed for quality. Currently, CMS is transitioning from a pay-for-reporting to a pay-for-performance system. The first step in this transition is value-based purchasing. CMS directs its influence through three main programs:
- Physician Quality Reporting System (PQRS). Providers are responsible for reporting PQRS measures via claims through their billing companies. These measures include Medicare Part B patients only, but do include both admitted and discharged patients.
- Outpatient Prospective Payment System (OPPS). Hospitals are responsible for reporting these measures, which include all patients, regardless of payer, with a broad range of dispositions including admissions, transfers, and discharges.
- Inpatient Prospective Payment System (IPPS). Hospitals are responsible for reporting these measures, which include all admitted patients, regardless of payer.
Physician Quality Reporting System
The 2006 Tax Relief and Health Care Act (TRHCA) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals who satisfactorily submitted data on quality measures for covered professional services furnished to Medicare beneficiaries beginning in the 2007 reporting period. This CMS program was formerly known as the Physician Quality Reporting Initiative (PQRI). In 2011, a name change occurred, and the program is now known as the Physician Quality Reporting System to denote that it is no longer a pilot but rather an established program. The title of the program, however, is a misnomer as the program applies not only to physicians but also to physician assistants and nurse practitioners.
Provider-based measures largely originate from the AMA-PCPI (Physician Consortium on Performance Improvement, convened by the American Medical Association). The current PQRS measures are listed in Table 1. For 2012, there were a large number of new measures, with seven that are relevant to emergency medicine. Pending National Quality Forum (NQF) measure review and the endorsement process, it is possible that some of the current PQRS measures will be retired. A number of proposed additional measures are being considered for future PQRS implementation such as confirmation of ETT, pediatric weight in kilograms, and ultrasound guidance of IJ CVC placement.
The schedule for additional financial incentives and penalties for reporting PQRS measures is outlined in Table 2.
Outpatient Prospective Payment System
Hospital measures can originate from individuals, professional societies, academic institutions, and more recently, consulting agencies such as Optimal Solutions Group and Ingenix. The bulk of hospital measures that affect emergency medicine (Table 3) come from the OPPS and its associated data reporting program, the Hospital Outpatient Quality Reporting (OQR) Program. The Hospital OQR Program was mandated by the 2006 TRHCA, which requires in Subsection (d) for hospitals to submit data on measures on the quality of care furnished by hospitals in outpatient settings. To receive the full annual payment update (APU) under the OPPS, hospitals must meet administrative, data collection and submission, and data validation requirements of the Hospital OQR Program. Hospitals that fail to successfully participate in the OQR receive reduced payments through a reduction of 2.0 percentage points to the hospital market basket update.