This is the third in a series of blog posts on government incentive programs. See the prior blog posts on Incentive Program Confusion and The eRx Incentive Program.

Let’s face it: for most providers, the King of All Government Incentive Programs is the EHR Incentive Program aka Meaningful Use (MU). Well, if MU is the King, then PQRS is the Prince. The reason why PQRS is the prince is that, unlike the eRx program, there is still some upside for MU EHR users in the PQRS program. But PQRS can never be king because it pays so little when compared to the MU EHR program — for 2011, just 1% of Medicare Part B FFS approved revenue.

PQRS History

Ahh, Alphabet Soup. PQRS was established as part of The Tax Relief and Health Care Act of 2006 (TRHCA). It started as a voluntary bonus payment for eligible professionals (EPs) for reporting Physician Quality Reporting Initiatives (PQRI) to Medicare beginning July 1, 2007 through 2014. The recently passed Patient Protection and Affordable Care Act (PPACA) will require mandatory reporting in 2015 (and into the future) and also changes the name to the Physician Quality Reporting System (PQRS). It’s funny how these voluntary programs somehow morph into mandatory programs.

PQRS Program Mechanics

This is the boring, detailed part of this post. If you don’t have a Starbucks Venti-sized drink on your desk, then fast forward to the good parts, starting with the PQRS Economics section.

Reporting Methods Overview

Eligible professionals may report individual PQRS quality measures or measures in groups. Measure Groups are clusters of individual measures that have a particular clinical condition or focus in common. To report either individual measures or measure groups, providers can either (1) place special codes via Medicare Part B claims, (2) send data to a qualified PQRS registry that will report the data to CMS on behalf of the provider, or (3) report via a qualified EHR (only a select set of measures).

Measure Group Reporting (There are several methods)

30 Patient Method

Reporting Period: 12 month reporting period only.

For claims-based and registry-based submissions, report on 30 unique Medicare Part B FFS who meet the patient criteria for the measure group. All applicable measures within the group must be reported at least once for each patient.

50% Patient Sample Method via Claims or 80% Patient Sample Method via Registry

Reporting Period: 12 month and 6 month reporting periods are allowed.

Report on 50% of all patients during the measurement period if you report via claims, or 80% of patients if you report via a registry. In addition if you report for a full year, a minimum of 15 Medicare Part B FFS patients must meet the measures group patient criteria to report satisfactorily. For the 6-month reporting period, a minimum of 8 Medicare Part B FFS patients must meet the measures group patient sample criteria to report satisfactorily.

Fourteen measures groups have been established for 2011 Physician Quality Reporting.

Individual Measure Reporting

Reporting Period: 12 month and 6 month reporting periods are allowed.

Report on 3 or more measures unless the provider can attest that at least 3 measures do not apply to their practice. Also, report via claims on 50% of all patients or report via registry on 80% of all patients.

EHR ReportingReporting Period: 12 month reporting period only

Report on 3 or more measures unless the provider can attest that at least 3 measures do not apply to their practice. Also, report via EHR on 80% of all patients. The provider must upload the data exports from the EHR to CMS (which takes several hours and has a separate enrollment process).

Note: There are Medical Group Reporting and Maintenance of Certification features in 2011 (they are beyond the scope of this blog post).

PQRSEconomics
The following table compares the PQRS and eRx programs:

PQRS

eRx

Year Successful Not Successful Successful Not Successful
2009 +2.0% 2.0%
2010 +2.0% 2.0%
2011 +1.0%* 1.0%
2012 +0.5%* 1.0% -1.0%**
2013 +0.5%* 0.5% -1.0%
2014 +0.5%* No incentive -2.0%
2015 No incentive -1.5% No incentive -2.0%
2016 + No incentive -2.0% No incentive -2.0%

*An additional +0.5% PQRS incentive payment for participating in a Maintenance of Certification program
**2012 penalty based on eRx usage 1st 6 months of 2011 (see eRx blog post to learn more)

Remember, I said it was funny how these incentive programs morph into mandatory programs. After reviewing this table, I just thought of something even funnier: these incentive programs really morph into “penalty” programs.

As discussed in our previous post on the eRx incentive program, there is no upside/incentive for EHR Incentive MU users to participate in the eRx program: if they meet the MU incentive, they cannot collect the eRx incentive, but there is a penalty for not reporting the correct G codes this year that is assessed in 2012.

For PQRS program participation in 2011, there is still has some financial upside, even if you are participating in the EHR Incentive MU program. The obvious questions are: “How much incentive payment is possible? What do I need to do to get it? Can you make it simple for me?” OK, stay tuned!

Recap
An eligible professional who reports successfully will earn a payment equal to 1.0% of their total estimated allowed charges for Medicare Part B Physician Fee Schedule (PFS) covered professional services furnished during the longest reporting period for which he or she satisfied reporting criteria (either 6 or 12 months).

Get used to PQRS reporting, because unless the law changes, penalties are coming in 2015 for not being a “successful submitter”.

There are many confusing ways to report PQRS… Some requirements even ask you to create a code for each claim you send (degree of difficulty: next to impossible). Some of those methods make you report on a large percentage of your patients (50-80%, also a high degree of difficulty). The EHR method makes the provider, not the EHR vendor, upload files in small increments to CMS (too time consuming).

The MediTouch® Way to PQRS Incentives

What if I told you that you could submit PQRS data to CMS by just taking good care of your patients? What if I also told you that you only had to report on just 30 patients, and MediTouch EHR® would tell you which patients met the criteria? How about submitting to CMS… Wouldn’t it be great if someone else submitted the file for you?

If you answered yes to these questions, then MediTouch® PQRS is the solution for you. MediTouch has partnered with the American Osteopathic Association’s (AOA) CAP CMS Qualified Registry for PQRS file submission. We believe that the combined efforts of MediTouch EHR and the AOA CAP Registry will streamline your PQRS submission process.

Conclusion
PQRS is confusing. Without help, it is never worth the 1% of fees that comprise the CMS incentive. With the MediTouch EHR measure group registry method, providers that collect a significant amount of FFS Part B dollars should be able to get a few hundred dollars of economic benefit from PQRS for 2011 without too much effort. We believe we have made it simple enough, but don’t forget the bigger prize: the thousands of dollars of EHR Incentive MU dollars available over this year and the next few years.