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From Health Law Daily, April 4, 2014

Participation rises in two CMS pay-for-reporting programs

By Harold M. Bishop, JD

CMS has issued a report summarizing the reporting experience of eligible professionals (EPs) in the Physician Quality Reporting System (PQRS) and Electronic Prescribing (eRx) Incentive Program in 2012, including historical trends and preliminary results for the 2013 program year. The report indicates that the number of EPs who participated and earned an incentive in the programs continued to grow in the 2012 program year. In addition, most EPs who participated in either program were successful reporters and qualified for an incentive payment. The report’s findings measure incentive payments paid, expansion of the programs, participation levels, program eligibility, incentive eligibility, and payment adjustments.

The programs. The PQRS, (formerly, Physician Quality Reporting Initiative or PQRI), authorized under Section 101(b) of division B of the Tax Relief and Health Care Act (TRHCA) of 2006 (P.L. 109-432), encourages EPs to report data on quality measures. The PQRS entered its sixth year in 2012 and has grown substantially from its inception in 2007. The eRx Incentive Program, authorized under Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (P.L. 110-275), was introduced in 2009 as a separate incentive vehicle to encourage EPs to report electronically.

EPs for the PQRS and e-RX Incentive Program include the following: physician, physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, clinical social worker, clinical psychologist, registered dietitian or nutrition professional, audiologist, physical or occupational therapist, or qualified speech-language pathologist.

Both these programs encourage EPs to report clinical quality measures by providing a series of payment incentives, based on a percentage of the total estimated Part B Medicare Physician Fee Schedule (MPFS) allowed charges for covered professional services furnished by the EP during the reporting period, and payment adjustments, based on a percent reduction in MPFS payment amounts.

Beginning in calendar year 2012, a payment adjustment was applicable to EPs who were not successful electronic prescribers under the eRx Incentive Program. Beginning in 2015, the PQRS applies a payment adjustment to EPs who do not satisfactorily report data on quality measures for covered professional services.

Incentive payments. The report found that: (1) EPs earned combined incentives of $503,146,409 through the PQRS and the eRx Incentive Program in the 2012 program year; (2) the number of EPs who qualify for an incentive payment under the PQRS and eRX Incentive Program has increased each year since their inception; (3) a total of $167,815,193 in PPQRS incentive payments were paid by CMS for the 2012 program year, reflecting the successful participation of 29,254 practices that included 367,228 eligible professionals; and (4) a total of $335,331,216 in eRx Incentive Program incentives was paid for the 2012 program year, which included 227,447 EPs and 55,015 practices meeting incentive eligibility criteria.

Expansion and eligibility. The report found that the 2012 PQRS and eRx Incentive Program generally retained the same reporting options (individual reporting options and group practice reporting options) as well as mechanisms (claims, registry, electronic health records, and web interface) from the 2011 program. However, under the Medicare Shared Savings Program and Pioneer Accountable Care Organization (ACO) Model, EPs that were part of an ACO were able to earn a PQRS incentive by participating via the ACO Group Practice Reporting Option (GPRO) web interface in 2012. In addition, 68 practices self-nominated and were approved by CMS to participate in the PQRS in 2012 under the GPRO, nine under the Small GPRO (25 to 99 EPs) and 59 under the Large GPRO (100 or more EPs).

Participation rate. The report found that: (1) the number of EPs who participated increased by 36 percent and 22 percent for the PQRS and eRx Incentive Program, respectively from 2011 to 2012; (2) in 2012, 435,871 (36 percent) EPs participated in the PQRS, Medicare Shared Savings Program, or Pioneer ACO Model through at least one method, a four-fold increase from the roughly 100,000 who participated in 2007; (3) the participation rate among all EPs using any method to participate in the PQRS increased from 15 percent to 36 percent between 2007 and 2012; and (4) in 2012, 19,817 EPs submitted quality data for the PQRS through a qualified EHR, while 7,858 EPs submitted quality data through the eRx Incentive Program EHR mechanism.

Incentive eligibility. Across all reporting options, the report found that more than eight in 10 participants (84 percent) in the 2012 PQRS met the criteria for incentive eligibility. In addition, two-thirds of EPs (66 percent) who participated in the 2012 eRx Incentive Program qualified for an incentive.

2013 eRx payment adjustment. The report found that 59,955 EPs were subject to the 2013 eRx payment adjustment because they either did not qualify for an exemption, meet exclusion criteria for the adjustment, were not successful e-prescribers in 2011, or did not meet eRx reporting requirements in the first half of 2012. In addition, over 75 percent of those subject to the payment adjustment did not participate in the eRx Incentive Program at all.

MainStory: TopStory ReimbursementNews ACONews CMSNews DrugBiologicalNews EHRNews HITNews PartBNews PhysicianNews PrescriptionDrugNews QualityNews

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