AMA survey results: Medicare rated as poor performer during debut of pay-for-reporting

Physicians will decide whether to participate in 2009 without knowing if they will receive a bonus for 2008.

By — Posted Nov. 17, 2008

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Even as Medicare's Physician Quality Reporting Initiative approaches the end of its 2008 run, many doctors are still trying to figure out what went wrong with the 2007 PQRI.

Confidential physician feedback reports from last year's initiative, which for the first time offered Medicare bonuses for successfully reporting quality measures, became available to participating practices starting in August. Since then, many participants have been struggling to make sense of the information that they received -- if they were able to access it at all.

Only about 20% of 408 physicians surveyed in September by the American Medical Association were able to download their 2007 feedback reports, which told each doctor whether he or she reported enough measures to qualify for a bonus. Nearly 60% of those who sought assistance from the Centers for Medicare & Medicaid Services in accessing the confidential reports said they received little to no help from the agency. For physicians who persisted and were able to get past the stringent security measures, fewer than half said they found the data instructive.

"The AMA is committed to working with policymakers to make this program a viable quality improvement tool for physicians," said AMA Secretary Ardis D. Hoven, MD. "The survey shows a clear need for the program to be improved so that physicians can more easily participate and so that they and Medicare get greater value from the program."

Physicians' poor reviews of the initial six-month run of PQRI come at a critical time. For the 2009 reporting period that will start Jan. 1, the potential physician bonus will rise from 1.5% of all Medicare charges for the year to 2%. CMS officials hope to attract enough participants to the pay-for-reporting effort that it can develop into a robust pay-for-performance and quality improvement element for Medicare somewhere down the line.

But physicians who make the decision to participate in 2009 will be flying blind in one major way. Because they will not receive confidential reports on their 2008 reporting until the middle of next year, doctors will not officially know if they took the correct steps to secure a bonus until most of the upcoming yearlong reporting period has already passed. If some physicians don't qualify for a 2008 bonus because they are not reporting correctly or their necessary information is not making it to CMS, they may find out the problem too late to salvage a bonus for 2009 as well.

Because of this high degree of uncertainty -- and the fact that nearly half of participants in 2007 failed to qualify for an incentive payment -- the AMA and other physician organizations are calling for major changes to PQRI. The Association is asking CMS to improve physician education and provide much quicker feedback to doctors so they can better determine if they are on track with their reporting before it's too late. The AMA also wants physicians who are denied bonuses to be able to appeal the decisions, something that is not allowed under the current system.

Worries about 2009

Absent such changes, Patricia A. Cosgrove, MD, said she cannot know whether her practice will be successful in PQRI this year or the next. The Bozeman, Mont., ophthalmologist's four-member practice reported quality measures in 2007, but she and two of her colleagues failed to receive bonuses, and the payment for the one doctor who qualified was significantly smaller than expected. The feedback reports that the practice downloaded with much difficulty and subsequent follow-ups with CMS have not been helpful in shedding any light on what went wrong.

"It is such an exercise in frustration to do everything we're asked to do and then to not meet criteria and be talking into a void when it comes to trying to figure out how we can amend what we're doing," Dr. Cosgrove said. "We're just trying to do the right thing."

Because the office's own records on its quality reporting don't match what CMS noted on the reports, the physicians worry that Medicare is making errors somewhere and that their ability to obtain full-year bonuses for 2008 reporting is also in jeopardy. Still, the practice plans to keep reporting measures as best it can in 2009.

Although PQRI is voluntary, the incentives for physicians to participate keep ramping up. In addition to increasing the bonus size, CMS is making plans to share publicly the names of physicians who are successful quality reporters on its Physician Compare Web site, starting sometime in 2010. Dr. Cosgrove worries that any patient looking for her name on the site and not finding it might get the mistaken impression that her quality of care is somehow subpar.

"I don't see it as being voluntary," she said.

Some participating California doctors suspect they received no PQRI bonus for 2007 because the contractor handling the quality data said its system had no record of their practices. Physician delegates from the state proposed a resolution for the AMA's Interim Meeting in November that would direct the Association to register a formal complaint with CMS and seek restitution for doctors who were erroneously denied bonuses.

Medicare acknowledges criticism

Some physicians already have given up on PQRI. About one-quarter of the respondents to the AMA survey said they had decided to drop out based on their 2007 experiences. Nevertheless, CMS is confident that many other doctors have worked through any problems that arose during the initiative's debut and are in much better shape to achieve success this year and beyond, said an agency official who asked not to be identified so he could speak freely about the initiative.

CMS will continue to educate physicians about how to report quality measures correctly, the official said. The agency soon will release a list of common reporting problem areas encountered by physicians who failed to achieve bonuses in the 2007 PQRI. But producing faster personalized feedback to physicians would be more difficult because most of the reporting period would already be over before Medicare even had enough quality reporting data to compile in a report, he said.

The CMS official acknowledged doctors had a legitimate criticism that the 2007 feedback reports did not contain more detailed information. The agency already has plans to address that concern by including additional data in the 2008 feedback reports on how many reported measures were invalid and why those measures could not be counted.

CMS is focused on trying to get as many physicians as possible on board with PQRI in 2009 by expanding the quality measures that they can report and the ways that they can report them, the official said. "It's important to focus on what we've learned from the 2007 program, but I also think it's important not to dwell on it."

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Poor grades for Medicare

More than 400 physicians responded to an AMA survey on Medicare's 2007 Physician Quality Reporting Initiative. Many reported problems and dissatisfaction. About a quarter of respondents said they planned to drop out of the initiative.

Did you or your staff access the 2007 PQRI feedback report for your practice?
Yes, successfully downloaded it22%
No, no interest in reviewing it4%
No, but might in the future11%
No, attempted to, gave up and have no intention of trying again10%
No, attempted to, gave up but intend to try again18%
No, not aware report could be downloaded17%
Please rate your satisfaction with CMS responsiveness to your requests for assistance.
Based on your participation in the 2007 PQRI, do you plan to participate or continue to participate in the ongoing PQRI program?

Note: Not every respondent answered every question.

Source: American Medical Association

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