Key Point

Information is readily available for all physicians about the Physician Quality Reporting Initiative, a pay-for-performance program used by the Centers for Medicare and Medicaid Services.

HONOLULU—Pay-for-performance (P4P) incentive programs, which have become popular among health care payers as a means to reward providers for quality, follow the same trajectory as rock stars, said Andrew B. Egol, DO, MBA, at the Society of Critical Care Medicine’s 37th Critical Care Congress.

“When you first hear about a rock star, you initially think that this is a new career for him, but he has actually been doing this for 10 or 15 years before he became famous,” explained Dr. Egol, Vice President of Medical Affairs at the University Hospital and Medical Center in Tamarac, Florida.

Pay for performance actually has been around for that long already, mostly under the purview of managed care companies in the western United States, and in the setting of ambulatory care. “We are only starting to hear about it now because the largest payer in the country—Medicare—has begun to take an interest in it,” Dr. Egol pointed out.

The Physician Quality Reporting Initiative (PQRI), which is what the Medicare P4P program is called, is open to many types of providers and those from a variety of specialties. The Medicare definition of physician, noted Dr. Egol, includes doctors of medicine, doctors of osteopathy, podiatrists, optometrists, oral surgeons, dentists, and chiropractors. Physician assistants, nurse practitioners, clinical nurse specialists, physical therapists, and occupational therapists are among the many professionals included in the definition of “other providers.” Any clinician who bills Medicare can use any of the 119 currently approved PQRI measures, if applicable to that provider’s practice.

Providers who want to use PQRI should take advantage of instructional webinars such as those provided by the Centers for Medicare and Medicaid Services (CMS). The most recent of these CMS webinars “is a 47-page PDF document, which is the blueprint for how to use PQRI,” related Dr. Egol.

There is no need to register for PQRI in order to begin reporting. To be eligible, providers must be enrolled in Medicare (a signed contract is not required) and have a national provider identifier number. Tax ID numbers are not accepted.

“The more measures you use, the better off you are,” Dr. Egol explained. “If you report three measures or less, you have to report them correctly 80% of the time. If you use four or more, you only have to report three of them correctly 80% of the time. Your chances of getting a good outcome increase with the more measures you use.”

PQRI is a numerator and denominator program, added Dr. Egol. A score for each quality measure is determined by dividing the total number of the corresponding interventions performed by the total number of cases meeting the criteria necessary to be part of the target population for a particular measure. These individual scores are then combined into an annual composite quality score that is used to establish baseline performance and rank a provider by decile. The decile ranking determines the financial incentive awarded.

Health care providers participating in PQRI also will need to be familiar with data codes or modifiers. These codes are used to report whether a particular performance measure was met and to explain reasons for noncompliance.

The 1P code, for example, denotes exclusion for medical reasons, while 3P denotes exclusions for system reasons; 8P means “reason not specified.” The 8P modifier should be avoided as much as possible, because providers receive no credit for P4P measures not adhered to without a specific reason, Dr. Egol explained.

At the CMS Web site www.cms.hhs.gov/pqri, providers can find everything up-to-date and necessary for proper PQRI reporting, such as complete information on all PQRI measures, as well as downloadable tools, such as the data collection worksheets used to gather specific patient data, said Dr. Egol. Physician specialty Web sites can also be a good source of such information.

Dr. Egol concluded that P4P is here to stay, although exactly how it ultimately will provide financial incentives for quality care is still undetermined. Providers will be either paid for their performance or penalized for poor quality, he said.

—Timothy Begany

Suggested Reading
Glickman SW, Ou FS, DeLong ER, et al. Pay for performance, quality of care, and outcomes in acute myocardial infarction. JAMA. 2007;297(21):2373-2380.
Landon BE, Normand SL. Performance measurement in the small office practice: challenges and potential solutions. Ann Intern Med. 2008;148(5):353-357.
Lexa FJ. Pay for performance and the revolution in American medical culture. J Am Coll Radiol. 2008;5(3):168-173.

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