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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