This article aims to provide background on quality measure reporting and reimbursement programs, as well as to update readers on the current, future, and disabled quality measures relevant to the practice of emergency medicine.
Explore This IssueACEP News: Vol 30 – No 11 – November 2011
The Centers for Medicare and Medicaid Services (CMS) remain the dominant player in the determination of how hospitals and providers are reimbursed with respect to quality.
The CMS directs its influence through three main programs: the Physician Quality Reporting System (PQRS), the Outpatient Prospective Payment System (OPPS), and the Inpatient Prospective Payment System (IPPS).
While hospitals are responsible for reporting the “core measures” (i.e., OPPS and IPPS programs), providers are responsible for reporting PQRS measures via claims through their billing companies. The OPPS and IPPS apply to all patients regardless of payer, with admitted patients reported via the IPPS and discharged/transferred patients via the OPPS. PQRS measures include admitted and discharged Medicare Part B patients only.
Physician Quality Reporting System (PQRS)
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 report 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) or the Pay for Performance (P4P) program. In 2011, the name was changed to the Physician Quality Reporting System (PQRS) to denote that it is no longer a pilot but rather an established program.
Provider-based measures largely originate from the AMA-PCPI (Physician Consortium on Performance Improvement, convened by the American Medical Association). This year, there are no additional measures that affect emergency medicine. Current PQRS measures are listed in Table 1; the new emergency department–relevant PQRS measures for 2011 are measures 91-93.
In addition, a number of proposed additional PQRS measures are now being considered for future implementation (see Table 2).
The schedule for additional financial incentives and penalties for satisfactorily reporting PQRS measures are outlined in Table 3.
Also, beginning in 2011, physicians will have the opportunity to earn an additional incentive of 0.5% by working with a Maintenance of Certification (MOC) entity and by 1) satisfactorily submitting data on quality measures under PQRS for a 12-month reporting period, either as an individual physician or as a member of a selected group practice; and by 2) participating in an MOC program and successfully completing a qualified MOC program practice assessment.