Basing their rationale on multiple publications from Institute of Medicine (IOM), specifically
Crossing the Quality Chasm, policy makers have focused on a broad range of issues,
including assessment of the influence of medical practice organization structures on
quality performance and development of quality measures. The 2006 Tax Relief and Health
Care Act established the Physician Quality Reporting System (PQRS), to enable eligible
professionals to report health care quality and health outcome information that cannot be
obtained from standard Medicare claims. However, the Patient Protection and Affordable
Care Act (ACA) of 2010 required the Centers for Medicare and Medicaid Services (CMS) to
incorporate a combination of cost and quality into the payment systems for health care as a
precursor to value-based payments. The final change to PQRS pending initiation after 2018,
is based on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which
has incorporated alternative payment models and merit-based payment systems. Recent
publication of quality performance scores by CMS has been less than optimal.
When voluntary participation began in July 2007, providers were paid a bonus for reporting
quality measures from 2008 through 2014, ranging from 0.5% to 2% of the Medicare Part
B allowed charges furnished during the reporting period. Starting in 2015, penalties started
for nonparticipation. Eligible professionals and group practices that failed to satisfactorily
report data on quality measures during 2014 are subject to a 2% reduction in Medicare
fee-for-service amounts for services furnished by the eligible professional or group practice
during 2016. The CMS proposed rule for 2016 physician payments contained a number of
provisions with proposed updates to the PQRS and Physician Value-Based Payment Modifier
among other changes. The proposed rule is the first release since MACRA repealed the
sustainable growth rate formula. CMS proposed to continue many existing policies
regarding PQRS from 2015 to 2016. In addition, 2016 will be the year that is utilized to
determine the 2018 PQRS payment adjustment. However, after 2018 the PQRS payment
adjustment will be transitioned to the Merit-Based Incentive Payment System (MIPS), as
required by MACRA. Overall, there will be over 280 measures in the 2016 PQRS.
Readers might be surprised to find out that despite the cost intensity including time
requirements personnel, the negative payment adjustments, are only the tip of the
iceberg of cost. Indeed, all of the above may only be one-third or one-fourth of the
cost to completely implement the PQRS system. Thus far, data across all specialties shows
participation to be around 50%. In addition, penalties for lack of reporting of PQRS
measures stands to be controversial to the Supreme Court ruling that unfunded mandates
must not be permitted and also lack of significant relationships with improvement in quality
in the overall analysis in multiple publications.
Key words: Value-based modifier, Medicare Access and CHIP Reauthorization Act of 2015
(MACRA), alternative payment models (APMs), merit based payment systems, negative
payments, bonuses
Physician Quality Reporting System Program Updates and the Impact on Emergency Medicine Practice
