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What is the future of the PQRS?

A lot of people ask me, “What is the future of PQRS?” I typically answer as follows:

I believe that PQRS is here to stay. Its name may change. Its protocols, methods, and requirements will evolve, and the vendors, tools, or consultants you turn to for help will change. But as a provider serving Medicare patients, expect that for the foreseeable future, there will be some kind of inducement or requirement to deliver data to Medicare about the quality of your care. And expect that the level of payment you receive from Medicare for your care will be tied to that data.

Underlying everything is a fundamental shift in Medicare strategy. Medicare is determined to migrate from the Fee for Service system to a Value-Based Purchasing system. Movement is slow and the environment is one of experiment, chaos and volatility. Medicare is testing a lot of programs to see what works and has shown a willingness to significantly adjust the approach annually. If you look carefully you can see the agenda in solid, decades-old, here-to-stay programs and well as in a myriad of new “how-long-will-they-last” programs. Each Medicare Program in the list that follows either directly adjusts payment on some type of quality metric, or incents the adoption of systems that help to store and deliver quality metrics:

The Acute Inpatient Prospective Payment System (DRGs), the Readmissions Reduction Program, the ePrescribing Incentive Program, the Physician Quality Reporting Program, the EHR Incentive Program, the Value-Based Payment Modifier Program, Hierarchical Condition Codes, the Shared Savings Program, the Advance Payment ACO Model, the Pioneer ACO Model

As PQRS (or it successor) evolves, expect:

Requirements will become more stringent. We are in a phase where Medicare is testing the system, building a reporting infrastructure, and trying desperately to increase participation. They have given us a lot of reporting options. The number of measures required is low. There is a nearly non-existent quality benchmark requirement. They make it absurdly easy to avoid penalties (adjustments). When the system is working more smoothly and participation levels approach Medicare goals, expect those requirements to become more stringent.

Expect to move to a single standard set of measures and methods. It is Medicare’s stated intent to move all of the above programs toward the PQRS standard measures and methods. In coming years expect measures and methods that are peculiar to other programs to either be phased out or to be added to the panel of methods and measures available in the PQRS program. Expect that a single PQRS submission will eventually satisfy the data requirements of any of the CMS programs that require quality data.

Expect to start reporting as groups instead of as individuals. 2013 marks the first significant movement in this direction. Medicare has redefined the Group Practice Reporting Option to make it easier, more attractive, and to be applicable to groups with as few as two providers. Medicare’s Value-Based Modifier, also introduced in 2013, introduces a new penalty that can only be avoided by making a PQRS submission as a group using the Group Practice Reporting Option.

Expect a larger measure load. Today, it takes only one measure to avoid the PQRS penalty and three measures to earn the PQRS incentive. Meaningful Use requires six to nine measures. One of the Group Practice Reporting options requires 29 measures.

You will eventually have to meet significant quality benchmarks. Today, PQRS remains, predominantly, a Pay-for-Reporting system. The only concession to a benchmark quality requirement is that they will not accept a zero performance rate to qualify a provider for incentive. They still accept a zero performance rate to avoid the penalty. I think we are still many years away from a stringent benchmark quality requirement, but it will come.

There will be more money on the line. In 2013, the PQRS incentive is 0.5% of allowable charges and the penalty (adjustment) is 1.5%. Within the next 5 years, with the programs now in place, a provider who is not keeping up with any of the programs faces a cumulative penalty (adjustment) that could be as high as 13% of Medicare allowable charges.

The data will be made public. It’s already started at a rudimentary level. Medicare has built a website called the “Quality Care Finder” that it hopes will eventually become a place where beneficiaries choose their healthcare providers based on comparative quality. Today, the only quality data available about a provider is a statement that they participate in the PQRS program (if they do).

Expect it to remain confusing, and complex. I’ll do my best to keep you apprised in clear and simple language of changes that are likely to be of importance to you and to keep you apprised of approaching decision points and deadlines.

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