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QUALITY


Penalties add up Bonuses shift to penalties in Medicare quality initiatives


BY AMY LYNN SORREL Putting off Medicare’s quality reporting initiatives could take a financial toll on physicians as many of the current incentives shift to penalties over the next couple of years.


Those programs include the Physician Quality Reporting


System (PQRS), e-prescribing, meaningful use of electronic health records (EHRs), and, eventually, a value-based modifier that will automatically adjust physicians’ Medicare payments based in part on PQRS performance. Come 2015, the intersection of these federal programs and their associated penalties could add up to a 5- to 6-percent hit to physicians’ Medicare income for those who have not successfully participated in the multiple pro- grams beginning in 2013. That’s because Centers for Medicare & Medicaid Services (CMS) policy generally back-dates the reporting requirements, meaning that physi- cians face a penalty based on their performance in the year or two prior.


Physicians will have to do their own math to determine the cost of participating or foregoing par- ticipation in the various initiatives, says Austin internist Ghassan F. Salman, MD, a member of TMA’s Council on Health Care Quality. Nevertheless, those choosing not to report risk leaving a significant amount of money on the table. Particularly with the shift to value-based payments on the


Salman, chief executive officer (CEO) of the Austin Diagnostic Clinic (ADC).


The multispecialty group has participated in PQRS and the


other initiatives since their inception. But even when the in- centive payments go away, the quality improvements reaped will remain, Dr. Salman says. “Money alone is not going to improve quality.” Nor is the trend likely to disappear, with commercial car- riers on Medicare’s heels, says Gregory S. Sheff, MD, medical director of care management and clinical integration for Aus- tin Regional Clinic (ARC).


The group participates in a


“Physicians with a large Medicare population stand to lose a lot of dollars.”


horizon, “from a financial standpoint it behooves physicians to start reporting in PQRS,” Dr. Salman said, adding that there is some time left to qualify for bonus payments. But money isn’t the only reason to get on board. “These programs will help our physicians provide better quality of care and more coordinated care. The problem is not the physicians. It’s the [health care] system, and the system is putting patients at risk. That’s what this [shift towards value- based care] all boils down to. And it can be done,” said Dr.


Blue Cross and Blue Shield of Texas primary care medical home model with similar structures, among other commercial quality programs. ARC, in affiliation with Seton Healthcare Family, is also part of a pioneer Medicare ac- countable care organization (ACO) that uses a risk-based payment structure and PQRS-like measures. “Medicare is determined to drive the system toward value- based payment on some level, and the way payers see it, it’s a bet- ter way to practice medicine,” Dr. Sheff said. But Dr. Sheff says physicians are in a position to take charge


and undo mistakes of the past. An example is private insur- ers’ tendency to rely solely on claims data to rate and reward quality.


“This is about putting the clinical and claims information to- gether to give the whole picture. And if we [physicians] don’t step up and do that, which we can through PQRS, someone else will do it for us.”


Penalties add up Medicare introduced PQRS in 2007 as a voluntary mechanism to encourage physicians to begin reporting their quality mea- sure scores. Those who successfully reported are eligible for


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