New Developments In Payment And Public Reporting Of Quality Of Care
The Centers for Medicare & Medicaid Services (CMS) has
significantly expanded its quality initiatives beyond inpatient
hospitals to other health care professionals and entities with the
recent release and issuance of several rules and determinations.
The Physician Fee Schedule Final Rule (PFS Final Rule) and the
Outpatient Prospective Payment System Final Rule (OPPS Final Rule)
expand CMS' policy of tying payment to the reporting of quality
data to physicians, certain other health care professionals, and
hospital outpatient departments. Three new national coverage
determinations (NCDs) define certain "never events" as
non-covered services for all suppliers and providers. This
expansion of "pay for reporting" is important because CMS
intends that these programs, including existing hospital inpatient
pay–for-reporting programs, will soon change so that
payment will be tied to how well a provider performs in meeting the
quality measures, rather than just on reporting.
The PFS Final Rule also provides eligible professionals with a
new incentive for implementing successful e-prescribing
capabilities. With this new incentive, physicians and other
eligible professionals will have an opportunity to earn an
additional four percent of allowable Medicare payments, if they are
successful in meeting both the quality reporting and e-prescribing
requirements.
Finally, to further CMS' policy of denying payment for
preventable medical conditions, CMS proposes to expand the hospital
acquired condition (HAC) policy beyond inpatient care to physicians
and other health care entities, and to deny payment altogether for
certain never events. The following is a discussion of the key
features of these new issuances.
Physician Quality Reporting Initiative (PQRI)
The importance of PQRI for physicians and other health care
professionals should not be underestimated. CMS has made it clear
that pay-for-reporting programs are the basis for transitioning to
"pay-for-performance" (called Value-Based Purchasing by
CMS). For physicians and other health care professionals, CMS is
required to develop and submit to Congress a Value-Based Purchasing
plan by May 1, 2010. This stepwise transition for health care
professionals from pay for reporting to Value-Based Purchasing
mirrors the approach used by Congress and CMS in developing
Value-Based Purchasing for hospitals, which is likely to take
effect by 2012, assuming recent legislation introduced in Congress
within the last few months is enacted.
The PFS Final Rule expands PQRI to include 153 quality measures,
which is more than the 119 measures in 2008, but fewer than the 175
measures in the proposed rule. The measures include the 2008 PQRI
measures plus certain measures endorsed by the National Quality
Forum (NQF) and/or AQA (formerly the Ambulatory Care Quality
Alliance). In addition to individual measures, the 2009 PQRI
program will include seven "measure groups," defined as a
subset of PQRI measures that have a particular clinical condition
or focus in common. Details regarding the specific measures and
measure groups that are included in PQRI for 2009 can be found at
www.cms.hhs.gov/pqri. Technical specifications
for reporting the measures and measure groups in the 2009 final
listing will be posted to the "Measures/Codes" tab of the
PQRI section of CMS' Web site no later than December 31,
2008.
Due to changes made by the Medicare Improvements for Patients
and Providers Act of 2008 (MIPPA), PQRI is now codified as a
permanent program. CMS is now authorized to make incentive payments
to eligible professionals for reporting on applicable quality
measures into the future. For 2009, the eligible professionals
include certain mid-level practitioners, physicians, occupational
therapists, qualified speech-language pathologists, and qualified
audiologists...
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