CMS to merge PQRI with Meaningful Use

The Affordable Care Act of 2010 (the “healthcare reform bill” enacted earlier this year) contains a provision that requires the Center for Medicare and Medicaid Services (CMS) to integrate Meaningful Use with PQRI. In a proposed rule by CMS, setting payment policies for Medicare Part B payouts to physicians for calendar year 2011, CMS starts the steps towards such integration.

The Physician Quality Reporting Initiative (PQRI) was established by legislation passed in 2006, and is a way for physicians to report quality metrics to CMS and receive bonus pay-for-performance payouts for good performance. PQRI includes a set of 175 measures, grouped into 13 different groups – mainly around disease states, such as diabetes and chronic kidney disease, but it also includes a preventive care measure group.

Reporting of performance by physicians to CMS has traditionally been done by including zero-dollar CPT-II codes along with ordinary billing codes for patient encounters. No enrollment is needed for participation in the PQRI program – simply include the appropriate CPT-II codes along with ordinary CPT-based billing, and CMS will tally up the results and issue bonuses as they are earned.

CMS has also had more automated ways of reporting PQRI measures, besides simply claims-based reporting. Hospitals, large medical groups, and some Electronic Health Records (EHR) systems used in those settings, have created Registries for collecting PQRI data, and reporting such data to CMS periodically in the background. These registries often are focused on particular subsets of PQRI criteria, and usually have a free-standing web-based portal for physicians to manually enter this data if their EHR cannot dump data directly into them.

Another way of reporting PQRI data has been via direct reporting to CMS out of an approved EHR, bypassing any Registry. Reporting in this fashion is clearly the direction of the future, as alluded to in Meaningful Use documentation.

Meaningful Use
In 2009, the American Recovery and Reinvestment Act (ARRA) created incentives for physicians and hospitals to adopt HHS Certified EHRs, and demonstrate use of such technology in a “meaningful” way. The definition of what clinicians need to do in order to demonstrate Meaningful Use has been defined in a preliminary way, with a finalized set of rules anticipated soon.

The preliminary definition of Meaningful Use contains 25 criteria for EHRs used in ambulatory care (it is a similar but different set for hospital-based EHRs). Among these criteria are several that involve quality measurement, prompting, and reporting. For example, one proposed Meaningful Use criterion (criterion 14) states “implement five clinical decision support rules relevant to the clinical quality metrics the Eligible Provider is responsible for as described further in section IIA.” This is a reference to PQRI rules.

Putting it all together
The proposed rule CMS has announced integrating PQRI with Meaningful Use is the first step in formalizing this merger. From a monetary standpoint, CMS wants to phase out separate payment for PQRI performance, and roll it into Meaningful Use – what this means is that, going forward, physicians and hospitals won’t be able to access PQRI pay-for-performance money unless they are using an HHS Certified EHR.

CMS is asking for commentary about this proposal, once it is published in the Federal Register (anticipated on July 13). A preliminary non-final format is available for review now.

Is there any drawback to formalizing the PQRI measure set as the measure set for Meaningful Use? Well… maybe.

PQRI is a measure set developed by CMS for Medicare. As such, its measures are decidedly Medicare-oriented. The disease states measured are things seen in a Medicare population – diabetes, chronic kidney disease, congestive heart failure, ischemic vascular disease, etc. Even the Preventive Care Measures are senior-oriented: screening for osteoporosis, assessing for urinary incontinence in the elderly, influenza and pneumonia immunization, mammography, colon cancer screening, etc.

Given that Meaningful Use is deployed through CMS, the use of such a measure set is not surprising.

There is a different measure set – HEDIS – that has been preferred by commercial private insurers for their own quality metrics initiatives. In fact, in California, the Integrated Healthcare Association (IHA) – an organization of hospitals, health plans and medical groups designed to adopt a unified criteria set for pay-for-performance programs for commercially-insured patients – uses HEDIS (not PQRI) as the criteria set for this robust program.

Why? The HEDIS data set is much more focused at quality measures appropriate for younger non-Medicare populations. Though there is overlap (BMI measurement, diabetes management, etc), HEDIS also includes measures around childhood immunization status, immunization for adolescents, lead screening in children, Chlamydia screening in women, etc.

The merger of the PQRI incentive program with Meaningful Use seems like a natural evolution of two overlapping programs supervised by CMS. However, for Meaningful Use to have a broader implication beyond a Medicare-oriented population, recognition and adoption of other quality measurement sets (namely, HEDIS) is important. We look forward to a broader conceptualization of Meaningful Use outside CMS-covered populations. EHR adoption by clinicians nati
onally – including those whose practices center on populations not significantly covered by CMS, such as pediatricians – needs to be encouraged, in order that the vision of a truly interoperable Health IT infrastructure becomes a reality in this country.

Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR

Practice Fusion draws from a community of doctors, medical experts, and digital health influencers that contribute to blog posts.

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