What is PQRS, What is a QCDR and Why Should I Participate?

  • Qualified Clinical Data Registries (QCDRs) are new as of 2014, but their origin can be traced back to the Tax Relief and Health Care Act of 2006 in which Congress established the Physician Quality Reporting Initiative (PQRI). This initiative offered physicians a 1.5% payment bonus for reporting data on their quality of care to the Centers for Medicare and Medicaid Services (CMS). This initiative was made permanent and renamed as the Physician Quality Reporting System (PQRS) with the Medicare Improvement for Patients and Providers Act of 2008.
  • In PQRS, physicians are given a list of specific data items that CMS wants them to collect for a specific patient population. Physicians that hope to qualify for the incentive payment must choose a minimum of 9 measures from a large list of PQRS measures, and then report data on these measures to CMS every year. In addition, the 9 measures that are chosen must meet specific criteria for the list of 9 to be acceptable, such as covering different categories and types of data. The requirements for meeting these criteria and receiving the payment incentive are confusing, and the process required to qualify is cumbersome and potentially expensive, depending on how the data is collected and reported.
  • The problem is even greater for specialists, such as anesthesiologists, since the PQRS measures were not designed for specialists. Specifically, there are less than 9 measures that can be collected by anesthesiologists because the rest simply do not apply to our specialty and the work we do with our patients. The actual number that DOES apply to us varies depending on who you ask, but in 2016 there is only one PQRS measure available for anesthesiologists to report.
  • The way that CMS addresses this issue is called the Measure Applicability Validation Process (MAV process). CMS says that if you report less than 9 measures, they will subject your claim to the MAV process to determine whether THEY feel you should have reported more measures than you did. Unfortunately, they will not tell you how many measures you should be reporting ahead of time, and it is only after the reporting year is completed and you can’t do anything about it that they inform you of whether you have met their requirements.
  • QCDRs were established in 2014 as an alternative method for providers to meet their PQRS requirements. The idea behind a QCDR is that specialists, who know their field the best, should be the ones to determine which quality measures are relevant to their specialty. In a QCDR, instead of picking from the PQRS measures list, providers can create their own list of quality measures, subject to CMS approval. Once CMS approves this list, it can be used in place of the standard PQRS measures to meet PQRS requirements. For anesthesiologists, this means they can have 9 measures, NOT be subject to the uncertainty of the MAV process, and choose measures that are both relevant to their specialty AND that can be collected more easily with less expense.
  • To form a QCDR, you must have an established quality assurance database that is of adequate size and has participants from multiple anesthesia groups. This database must then submit a list of non-PQRS quality measures for approval, and must attest that it will meet several CMS requirements, including risk adjustment of the data, and the annual performance of data validation studies. Upon approval by CMS, QCDR personnel must obtain access to the CMS data portal that is used for QCDR data submission, and must post their policies, procedures and costs in a public place.
  • The Problem: The Affordable Care Act of 2010 changed PQRS by replacing incentive payments with penalties for non-participation starting in 2013. In addition, the payment reductions for a given year are based on participation 2 years prior. For example, a group’s PQRS participation performance in 2013 determines whether they are penalized with a payment reduction in 2015. A schedule showing incentives and penalties is shown below:
YEAR REPORTING YEAR PAYMENT ADJUSTMENT
INCENTIVE PAYMENT
2013 2013 +0.5%
2014 2014 +0.5%
PAYMENT ADJUSTMENT
2015 2013 -1.5%
2016 2014 -2.0%
2017 2015 -2.0%
  • For groups that were simply going to forego the PQRS incentive payment, that is no longer an option. Non-participation in the future will cost 2% of a group’s total Medicare revenue.

    In addition, non-participants will not be able to use PQRS to qualify for incentive payments available through the CMS Value Based Payment Program starting in 2015. With non-participation in PQRS becoming increasingly more costly as the years pass, many anesthesia groups are now rushing to make sure that they meet these requirements in one of the five currently available ways:

  • Claims Made reporting
  • Direct electronic health record (EHR) reporting
  • Qualified Registry Reporting
  • QCDR Reporting
  • Obtain an exemption through participation in an alternate CMS program.

While all of these methods are a viable means for PQRS reporting, the only one that addresses all of the problems for anesthesiologists outlined above, and is widely available to most anesthesia groups, is the QCDR option.