Turning point
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Incentives give way to penalties for quality reporting, while options for participation expand

The good news is that providers can still receive an incentive for participating in the Physician Quality Reporting System (PQRS) and they now have more options for doing so. The bad news is that those who do not participate will face a penalty.

Eligible professionals (EPs) who successfully report three quality measures in 2013 will receive a bonus payment of 0.5 percent of their Part B claims around October 2014 — the same bonus they were eligible for in 2012. New this year, providers in groups of two to 24 EPs are allowed to participate in PQRS reporting as a group practice. They must report on three measures. Previously, only groups of 25 or more EPs were allowed to participate in the PQRS Group Practice Reporting Option (GPRO).

The benefit of participating as a group practice is that billing and reporting staff may report one set of measures data on behalf of all EPs within the group. This will reduce the need to keep track of EPs’ reporting efforts separately, noted Oliver Wisco, DO, chair of the AAD’s Performance Measurement Task Force. [pagebreak]

In order to meet the definition of a PQRS group practice, the practice must have a single Tax Identification Number (TIN) with two or more EPs, as identified by their National Provider Identifier (NPI) number, who have reassigned their Medicare billing rights to the TIN. Physicians in group practices who want to participate in the GPRO must submit a self-nomination statement to the Centers for Medicare and Medicaid Services (CMS) by Oct. 15, 2013.

Cost of non-participation

This is the first year that penalties will be issued to EPs who do not participate in PQRS, though the reduction will not be immediate. Eligible professionals who fail to successfully report any measures in 2013 will see a 1.5 percent payment reduction in their Part B claims for 2015. If EPs report on only one measure for 2013, they will avoid the 2015 penalty, but they will not receive the 2013 bonus. Lowering this reporting threshold is CMS’ attempt to increase participation as it moves into a more value-based reimbursement structure, noted Alison Shippy, MPH, senior manager of quality for the AAD. Those who fail to successfully report in 2014 will see a 2.0 percent payment reduction in their Part B claims for 2016.

Providers who work in groups of 100 or more EPs will be subject to the value-based payment modifier (VBPM) in 2013. The VBPM offers a reward to EPs who are deemed to provide high-quality, low-cost patient care. Groups that do not satisfactorily report measures will receive a downward payment adjustment of 1.5 percent. Although most dermatologists will not be affected by this change as they typically do not practice in such large groups, the VBPM will be applied to all physicians beginning in 2017, per the Affordable Care Act. [pagebreak]

In addition to financial penalties, there are other negative consequences of not participating in PQRS. The AAD is trying to create a system in which the specialty’s performance can appropriately be measured, Dr. Wisco said. If dermatologists don’t participate in performance measurement initiatives, the specialty will miss an opportunity to collect the necessary data required to identify gaps in care or benchmarks down the road. “It’s a long process to develop a good quality metric. The quality measures we have right now are more like introductory measures to encourage dermatologists to participate in PQRS and quality improvement programs. But by no means are they perfect measures to improve quality and patient outcomes,” he explained. “Every specialty, with the exception of a few, is missing data that links measures to improved outcomes in practice.” The AAD is developing several ways to collect this essential data, he said, and the Academy’s Quality Reporting System (QRS) registry can potentially serve to accomplish this need.

For dermatologists who are part of accountable care organizations (ACOs) and larger groups, it is anticipated that not reporting quality measures will have a negative impact because those groups will start looking at performance measures to rate their physicians, Dr. Wisco added. [pagebreak]

Another downside of not participating is that CMS anticipates it will begin publicly reporting individual-level PQRS measure data gathered in 2014 on the Physician Compare website in 2015. Performance scores could negatively impact consumer choice, Shippy said. For example, patients may choose not to see a dermatologist who did not successfully participate in PQRS. Kathryn Schwarzenberger, MD, chair of the Academy’s Access to Dermatologic Care Committee, agrees that that scenario may play out in a highly competitive marketplace with a computer-savvy patient population. “But if you’re the only dermatologist practicing for miles around in a rural area, I’m not sure that it will have an impact,” said Dr. Schwarzenberger, who also serves on the Workgroup on Innovation in Payment and Delivery of the Academy’s Council of Government Affairs, Health Policy, and Practice.

“A dermatologist may be more willing to participate to avoid a negative stigma because there is the unfounded perception that a physician who doesn’t participate has something to hide,” added Dr. Wisco, who maintains that linking the two at this point is premature. “Just because you don’t report doesn’t mean you’re not a good physician.”

Holding back

There are myriad reasons why physicians, in general, and dermatologists, in particular, are not yet reporting quality measures in PQRS. [pagebreak]

“One of the biggest problems with quality reporting is that the burden is excessive,” Dr. Wisco said. Gathering the amount of patient information needed for a simple measure can require a lot of time and resources. “In theory, it’s a good idea,” he said. “But in practicality, it’s very time-consuming to input a year’s worth of data to report on just one measure.”

Dr. Wisco is not convinced that the penalty is significant enough to make a physician begin reporting when compared with the workload and resources that must be dedicated to the process. “I fully believe that we need to do this,” he added, “but I think the timing of implementation is what most of us question at this point.”

The lack of an electronic health record (EHR) that has the capability to gather data is another reason for non-participation, Dr. Schwarzenberger noted. Once EHRs can gather the data by doing a query or search, the process will become much easier.

Getting quality measures approved for PQRS participation is another stumbling block. It’s much easier to get measures related to primary care approved than it is to get dermatology-specific measures approved, she said. “The AAD is trying to develop meaningful quality measures that will enhance the care and well-being of our patients; the last thing we want to do is create busy work for our colleagues who are already overworked.” [pagebreak]

In addition to the existing three melanoma measures and a fourth one related to biopsy follow-up, two psoriasis measures have been submitted for possible inclusion in the PQRS program in 2014. The AAD submitted the measures to the agency in August 2012. More measures to report should entice more dermatologists to participate in PQRS.

Other factors that will play a role in getting more dermatologists to report measures include their participation in the American Board of Dermatology’s Maintenance of Certification program and meaningful use criteria for EHRs, Dr. Wisco said. As reporting of quality measures is more closely tied to payment by the federal government, ACOs, insurance companies, and others, participation is expected to increase. While Dr. Wisco understands this incentive, he disagrees with it in principle. “It’s unfortunate that improvement has to be tied to financial incentives because the real purpose of improvement processes is to improve, to ultimately ensure that our patients receive the most effective, data-driven care. It’s not to be penalized or to increase one’s financial gains,” he said.

Both Drs. Wisco and Schwarzenberger encourage dermatologists to begin reporting measures despite what may be viewed as a somewhat flawed quality reporting system as it currently exists. “It’s valuable to report quality measures now with the understanding that you’re helping the specialty move forward to build a better system, and that the system isn’t perfect,” Dr. Wisco said. “Everyone in medicine needs to start looking at ways to improve what we do. By participating now, dermatologists will be better equipped to accommodate changes that are coming about in a way that is truly beneficial to everyone,” he said. [pagebreak]

PAs report measures using own registry

Physician assistants (PAs) now have access to NetHealth’s 1stAscent Registry to report quality measures in PQRS.

The Society of Dermatology Physician Assistants (SDPA) began offering its members access to the registry in June 2012.

PA members who care for Medicare patients with melanoma and bill for these services using their individual NPI number are eligible to report on all four dermatology-specific measures, noted SDPA President-elect Jennifer Winter, PA-C. Any services billed as “incident to” under the physician’s NPI number should be reported under the physician’s registry.

Once the PQRS measures had to be reported through an electronic registry, PAs could not report them unless they had access to a registry. As a result, two years went by without any reporting for many PAs, leaving money uncollected from the government, Winter said. Subsequently, she negotiated a discount for SDPA members to access the NetHealth registry. “The discount is equal to our membership dues for the year, so it’s a membership benefit.”

The organization currently has approximately 1,900 members who are potentially eligible to report measures, she noted. In order to participate a PA need only sign up with an approved registry. (The registry fee will be discounted if accessed through the SDPA website.) An advantage to having PAs participate for 2012 is that the physician can offer his/her PAs a financial incentive that is actually paid by the federal government, Winter added.

Program timeline for 2013 reporting

February 2013: QRS registry for 2013 is open. See www.aad.org/QRS.

March 2013: Registry submits all data for 2012 to CMS.

Fall 2013: Reimbursement for 2012 arrives.

December 2013: Last chance to purchase registry to report for 2013.

January 17, 2014: Last day to submit 2013 data to registry.

Fall 2014: Reimbursement for 2013 arrives.

2015: Penalty for 2013 non-reporting applied.



PAs report measures using own registry
Program timeline for 2013 reporting