April, 2016:

Physician Quality Reporting (PQRS)

Jill Berger-Fiffy, MHA, FACMPE, Senior Consultant, Management Consulting Team

Physician Quality Reporting (PQRS)

PQRS was envisioned to be a driver to improve the quality of care provided to Medicare patients and was initially an “incentive program” focused around achieving evidence based goals.  With the “incentive” or pay-for-reporting stage now complete, medical groups and individual providers (defined by CMS as “Eligible Professionals) who have not met the reporting criteria in 2015 are faced with a -2% Medicare reimbursement “penalty”  effective January 1, 2017. Medical groups or Eligible Professionals who reported in 2013 or 2014 and received an incentive payment avoided any penalties in 2015 (-1.5%) or 2016 (-2%).

If your medical group or practice is now in the PQRS “penalty box” now time to prepare 2016 reporting. To achieve compliance, a threshold of at least 50% of the eligible instances (referred to as the numerator) of all Medicare patients (referred to as the denominator) must meet the criteria. There are four National Quality Strategy (NQS) domains which are categorized as Effective Clinical Care, Patient Safety, Communication and Care Coordination, and Community Population Health. Compliance must include at least nine measures; inclusive of one cross cutting measure for providers who have face to face encounters with patients.

What Can Practices Do to Prepare?


  • Determine the participants. Review your types of providers, roles and responsibilities. Confirm which EPs are eligible to participate and are billable providers such as primary care physicians, specialists, advanced practice providers, and some allied health providers.
  • Verify the workflows in the practice. Compare the care provided in the practice to the list of 2016 measures and determine which measures overlap with the current workflow and identify other measures which could easily be integrated.
  • Select the measures. Practices may consider reporting up to twelve measures to ensure compliance with the minimum of nine measures. Choose the measures most relevant to the specialty, the patients and the providers.
  • Initiate a discussion. Speak with medical and administrative leadership of the practice to offer recommendations on the suggested approach to comply with the program.
  • Prepare the team. Develop an implementation and training plan for the practice. Determine if the practice will build automated prompts in your electronic medical record or use questionnaires. Confirm which providers will be responsible for inputting this important data. Licensed or registered staff; such as Nurses or Medical Assistants can input some of the information saving time for EPs to attend to tasks at the top of their license.
  • Training. Data integrity is integral to meeting the requirements. Consider the team and determine what methods of training will be most effective. Choose from a variety of training methods such as hands on learning, train the trainer, posters, written reference materials, checklists and screen shots which describe the steps in detail.
  • Documentation. It is understandable that some Medicare patients will not meet the expected criteria. Prepare the team to document exceptions such as those which are medical, patient or system related. Proper documentation will exclude these patients from the denominator and will not affect your overall score. Consider on the spot observation, data extraction and shadowing as helpful methods to train and monitor registered medical assistants or nurses; as well as other billable providers.
  • Differentiate the reporting method. Select which of the three methods (i.e., Group Practice Reporting Option [GPRO], Claims Based, or through Certified Technology) is best suited for the practice. Be aware of the required timelines. For example, between now and June 30th, practices should self-nominate for the GPRO option. Practices will need to identify the reporting method (Registry, EHR Interface or certified survey vendor).

Benefits and Challenges

Practices are incentivized to participate in PQRS now that the penalty stage has begun. This penalty will continue in perpetuity with funds being shifted to practices complying with the program.  This reduction may be additive to other potential reductions in payments for the Meaningful Use (MU) and Value Based Modifier (VBM) programs.  The coupling of these programs can add substantial reimbursement penalties to practices  – potentially a 9% reduction in Medicare fee-for-service payments.

It is essential to understand the reporting capabilities of your Electronic Health Record. PQRS reporting capability provides an automated way to assess the current status and if the practice is meeting/exceeding the measures.  If you do not have a certified EHR product, a web based registry may be an option. These programs are widely available and easy to use.  These involve an upload of the data to the reporting registry.

Whether or not these measures do in fact improve care, remains to be seen. Some worry that the PQRS initiative is onerous and detracts from the work at hand which is diagnosing and treating health conditions.  Compliance with the measures may require additional data entry, staff, and may have little or no relevance to outcomes.   Providers may need to focus on other metrics due state and local health plan requirements. Research published in Health Affairs in March 2016 found that Medical Group Management Association (MGMA) practices spent 785 hours per physician and more than $15.4 billion on quality measure reporting programs. The study found that majority of time spent on quality reporting consists of “entering information into the medical record ONLY for the purpose of reporting for quality measures from external entities,” and nearly three-quarters of practices stated that their group was being evaluated on quality measures that are not clinically relevant.[1]

National outcry from the MGMA and various medical societies has been strong. As a result, there is an effort underway to combine Meaningful Use (MU) and PQRS in 2017.  These will evolve into the Merit Based Incentive System (MIPS).  The standards; not yet available, proclaim to measure quality, resource use, clinical practice improvement and meaningful use of Electronic Medical Record Technology.

In the interim, much preparation and planning are needed to avert payment reductions. Begin planning today. Time is of the essence!



Jill Berger-Fiffy , MHA, FACMPE Senior Consultant

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant


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