I know it is hard to believe, but the Physician Quality Reporting System (PQRS) is now in its eighth year of existence and this year there are more ways to play. Before we get to the details of participation, let’s consider what’s at stake:

  • 2014 is the last year for the PQRS “bonus.” Participate successfully, and collect 0.5% of your 2014 Medicare Part B allowable sometime in late summer 2015.
  • More importantly, successful participation in 2014 will permit you to avoid the 2016 PQRS penalty, a 2.0% reduction in your Medicare Part B allowable.
  • Last but not least, those of you in a practice with 10 or more providers (don’t forget to count your mid-level providers) are now in the “performance year” for the 2016 value-based payment modifier. You can find the details elsewhere, but if more than half of the providers in your practice fail to successfully report PQRS in 2014, CMS will tack on an additional 2.0% Part B reduction in 2016.

It’s important to note the numbers above are all additive. Granted the small positive incentive is based on your 2014 Part B allowable and the two penalties are based on your 2016 Part B allowable, but in total we are talking about a net loss worth 4.5% of your Part B allowable. Think about it as a nonparticipation fee.

Now that I have your undivided attention, let’s examine how we might stay out of harm’s way. I think the best way to approach this is to start at the top. Are you or your practice participating in one of the Centers for Medicare & Medicaid Services’ Accountable Care Organization programs? If so, double check those rules as you are likely receiving credit for PQRS when you report quality measures as part of one these Shared Savings programs. This is not universal, so please do check with someone in the know to confirm.

Individual vs. group

If you are not participating in one of the many CMS flavors of shared savings, your next decision revolves around the answer to the following question: Should I report quality measures as an individual provider, or should my medical practice report jointly using one of the CMS Group Practice Reporting Options (GPRO)? GPRO has been around since 2010 and is particularly attractive to large primary care and large multispecialty practices. Historically the measures available for reporting via GPRO were focused on the type of primary prevention metrics one might find in general practice. That has recently changed and today groups can report individual measures, much in the same fashion as one might report nine individual measures through a PQRS registry (see below). Outside of large vertically integrated health care systems, I have not come across nephrologists participating via GPRO.

Reporting as an individual provider

In my experience most nephrologists and nephrology mid-level providers report PQRS as an individual provider. Notice I said mid-level providers. Frequently overlooked when this was purely a positive incentive program, increasingly nephrology practices are reporting PQRS for their mid-level providers in an effort to avoid the PQRS and value-based payment modifier penalties referenced above. At a high level there are five ways to report PQRS as an individual provider this year:

1.     Claims-based reporting

2.     Registry reporting

3.     EHR Direct

4.     EHR Data Submission Vendor

5.     Qualified Clinical Data Registry (QCDR)

Before we take a quick look at all five, let’s go over a few ground rules. First, CMS continues to frown upon measures for which you report a zero-percent performance rate. They treat these as measures not reported. Stated another way, you fail. Not only do you leave the 0.5% 2014 incentive on the table, but you will incur the 2016 penalties referenced above. Second, while PQRS started as a pay-for-reporting program, it is evolving into a performance program. Your performance scores for measures or measures groups that you report are increasingly used to gauge the quality of care you deliver. Bottom line, pay close attention to the measures you elect to report.

Claims-based reporting

The granddaddy of PQRS reporting methods, claims-based reporting involves adding additional HCPCS codes to the claim submitted for PQRS eligible patients. Success in 2014 requires the provider to submit claims data for at least 50% of the eligible Medicare Part B beneficiaries for 9 individual measures that span 3 of the 6 National Quality Strategy (NQS) domains.

Avoiding the 2016 penalty is a bit easier than winning the 2014 incentive. Successfully reporting 9 in 3 will allow you to avoid the 2016 penalty. You can also avoid the penalty by reporting on at least 50% of your eligible Part B patients for 3 individual covering one NQS domain. Clear as mud right? One last important fact with respect to claims-based reporting in 2014: You can no longer report a measures group via claims.

Registry reporting

Registry reporting has been available since 2008 and is the only reporting method in place this year that supports measures group reporting. The popular CKD measures group is back and unchanged from 2013. The provider answers the same four CKD-related questions for 20 or more patients (as long as at least 11 are Medicare Part B beneficiaries). Registry participants also have the same 9 in 3 opportunity afforded to claims-based reporters for individual measures. They can also avoid the penalty by reporting 3 individual measures as noted for claims.

EHR Direct

If 9 in 3 sounds familiar it’s because the same criteria is required for the Clinical Quality Measure component of the Meaningful Use program. EHR Direct vendors are those vendors that have certified their EHR product to permit practices to directly submit PQRS measure data directly to CMS in CMS-specified formats.

If you choose this path, not only must your EHR be capable of submitting the data in the specified format, but you must make sure your vendor uses the eCQM specifications published in the June 2013 release. As with claims-based reporting, it’s 9 in 3 for 50% of your eligible Part B patients to win the 2014 incentive, and 50% of your eligible Part B patients for 3 individual measures simply to avoid the 2016 penalty.

EHR Data Submission Vendor (DSV)

An EHR DSV looks a lot like the EHR Direct path to PQRS. The difference is the DSV is responsible for passing the data to CMS on behalf of the provider. The file format and eCQM specification requirement noted for EHR Direct are basically the same. And as with claims, it’s 9 in 3 for 50% of your eligible Part B patients to win the 2014 incentive, and 50% of your eligible Part B patients for 3 individual measures simply to avoid the 2016 penalty.

Qualified Clinical Data Registry (QCDR)

The new kid on the block for 2014 is the QCDR. A QCDR is a CMS-approved entity that “collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients.” One of the advantages this new path brings to the table is the ability of the QCDR to develop its own unique measures and take those measures through the CMS approval process. The Renal Physicians Association, in collaboration with CECity, has launched a QCDR and plans to offer renal-specific measures in addition to standard PQRS measures. At the risk of sounding like a broken record, capturing the 2014 incentive requires submitting 9 in 3 data for 50% of the provider’s eligible Medicare Part B patients. If your goal is simply to avoid the 2016 PQRS penalty, you can report 3 individual measures for at least 50% of your Part B patients.

So many choices…what’s a doc to do?

In its drive to expand the options to report PQRS, CMS has certainly created complexity in this market. I think the key point this year is successful participation. Regardless of which method you choose, you need to successfully report PQRS this year to avoid the 2016 PQRS 2.0% penalty. If you practice in a group with 10 or more providers, reporting PQRS brings the added advantage of avoiding the additional 2.0% value-based payment modifier haircut in 2016. I think the ease of reporting the CKD measures group for 20 patients is going to be tough to beat, and I expect we, and others, will see another record-setting year with respect to Registry reporting.

If you have had success with claims-based reporting, I’d continue to pursue that path with the caveat that CMS is clearly moving away from claims-based reporting, so double check and make sure the measures you are reporting are still claims eligible. In future years, I would keep my eyes on the EHR reporting option and the QCDR opportunity. In 2015, the reporting periods for meaningful use and PQRS will align again, and I think the EHR reporting opportunity will be much more attractive. While few may be tempted to jump into the QCDR pool year one, the opportunity to report renal-specific metrics could become very attractive in the years ahead.

2014 is a pivotal year for PQRS. It is the last year this program will offer a positive financial incentive, the first year QCDR is available, and the first time the value-based payment modifier is in play for an increasing number of practices. Not participating will be expensive. Will you participate?