PQRI: ‘We’re from the Government, and We’re Here to Help’

Gerard J. Gianoli, MD, a member of the ENT Today editorial board, is an otolaryngologist in private practice in Baton Rouge, LA.

In 1976, Ronald Reagan said, The nine most terrifying words in the English language are ‘I’m from the government, and I’m here to help.’ Well, one of our government’s most recent attempts to help both physicians and patients has been PQRI-the Physicians Quality Reporting Initiative (see ENT Today, December 2008, page 12). For those of you not familiar with PQRI, it is a Medicare program whose purported purpose is to improve quality of care for patients and to dispense monetary rewards to physicians who practice good quality medicine. These two goals are set up with the backdrop of reducing Medicare expenditures-presumably on poor quality care. In the PQRI program, certain quality measures reported to CMS will result in a 1.5% bonus. In order to qualify for this bonus, the reporting physicians must follow certain guidelines in at least 80% of the cases reported. If you follow the guidelines in fewer than 80% of the cases, you get nothing.

In May 2007, I wrote a pessimistic letter to the editor regarding PQRI and predicted that the program would not improve quality and compliant physicians would not receive any significant monetary reward for their efforts.(1) My predictions were more optimistic than reality has borne out over the past year and a half. Not only does the program not reward physicians, but they are also monetarily punished, and there is no documented improvement in quality of care delivered.

The ‘Bonus’

From a purely incentive standpoint, the PQRI program will fail as it stands. In order for the program to succeed, physicians need to have a significant reward for their efforts. This is currently not the case. A single specialty group consisting of 14 physicians, two nurse practitioners, and one physician’s assistant illustrates this point.(2) The members of this group are clinically very busy, and they have graciously allowed me to report their PQRI experience. This group decided to participate with the 2007 PQRI program. They did everything correctly and by the book and received their bonus check from CMS in July 2008. The check was for a total payment of less than $305. No, not per clinician-for the entire practice. That amounts to about $18 per clinician. There were 1,136 codes reported, making the bonus payment per code 26 cents.

Many may say that even though this may seem to be very poor remuneration, it’s better than nothing. However, it’s actually worse than nothing. You have to consider what resources were employed to obtain this bonus, what are the consequences of being involved in this program, and you have to ask yourself if the resources employed playing this game would not have been better served elsewhere.

In order to participate in the PQRI program, the above-mentioned group had to review material from CMS and select codes to be counted. They developed an internal office form to collect data on each patient and spent time teaching the staff and physicians how to use the form and collect the data. As you may suspect, this required a fair amount of work from the administrative and clinical staff of this busy practice. Below is a breakdown of the clinic’s conservative estimate of hours and costs associated with setting up this program:

After this, the data were collected on a daily basis. The forms were filled out, the data was keyed into the computerized billing system and then the claims were submitted to CMS. The cost associated with the daily review of each form for proper coding after the clinician filled out the form:

Altogether, the total minimum cost for setting up the program and administering the program on a daily basis came to $5796.20. Of course, this does not take into account any payment for the clinicians’ time and effort. For the effort of the clinicians’ above and their expenditure of their staff of $5796.20 in salary, they received a bonus from CMS of about $305. So they lost more than $5000 in getting rewarded by CMS-and that reward came about seven months after the end of the program. Since the bonus was received well into the next reporting period (July 2008), if this practice had reported in error and received no bonus, they would have continued their errors for half of the 2008 reporting cycle.

Some may say that participation in the PQRI program could be performed with much less expense than the above practice experienced. They may be right, but keep in mind that more than half of the practices that participated in the 2007 PQRI program received absolutely zero in bonus payment. The bottom line is, if you don’t dot your is and cross your ts, you won’t qualify for a bonus. Also, keep in mind that CMS holds the full power of the federal government. Just as failure to fill out your income tax forms correctly could result in the government asking for money and penalties back, incorrect PQRI forms could result in givebacks, penalties, and possibly accusations of fraud.

Finally, you have to ask yourself: How many more patients could have been treated by this practice with the time the clinicians and staff spent filling out these forms? How much more patient care could have been delivered with the added $5796.20 spent on busy work directed towards the RNs’ salaries? (Roughly, there is one RN per physician at this practice for an entire workday.)

Needless to say, this group will not be participating in PQRI in the future.

A recent AMA survey(3) of physicians who participated in the 2007 PQRI program reported that 40% received a bonus, 29% did not, and 31% still did not know if they were going to get a bonus from CMS almost a year after completing the program. More than six in 10 physicians rated the program moderately, considerably, or extremely difficult, and only 22% were able to download their PQRI feedback report. And of those who could download the report, 59% rated their satisfaction with CMS’ information and responsiveness as none to low.

The Quality

PQRI has been promoted as a tool for improving the quality of medical care. I predict that it will not improve quality, will squelch innovation, and will punish doctors who try to keep their patients’ best interests in mind, while rewarding those who are good at paperwork.

Although PQRI just started in July 2007 and there are no published analyses of outcomes, we can perhaps get a glimpse of its future outcome by looking at its sister P4P (pay for performance) program employed with hospitals. P4P in hospital care started in 2003. Its focus has been the reporting of treatment for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. Although it has been demonstrated that hospitals that get bonus payments will report the quality measures at a higher rate than hospitals that don’t get a bonus,(4) actual outcomes in morbidity and mortality seem to be similar between the two groups. Comparing morbidity and mortality among 105,383 AMI patients in 54 P4P hospitals and 446 control hospitals, Glickman and colleagues(5) concluded that the pay for performance program was not associated with a significant incremental improvement in quality of care or outcomes for acute myocardial infarction. Similarly, Werner and Bradlow(6) looked at whether better conformity with P4P quality measures correlated with better outcomes among hospitals participating in P4P. In other words, did the better reporting hospitals actually get better risk-adjusted mortality rates? Among those hospitals scoring in the 25th percentile compared to those scoring at the 75th percentile, there were only small differences in hospital risk-adjusted mortality rates. So from the hospital P4P studies we know that (1) giving bonuses to the hospitals that report the data increases reporting, (2) the P4P program does not improve morbidity and mortality compared with those who don’t participate in the program, and (3) among those hospitals participating in P4P, there is minimal difference in outcomes between those with good reporting and those with bad reporting.

These results are surprising only until you realize that P4P (as well as PQRI) does not report quality. PQRI reports processes. Just because you give someone having an AMI an aspirin, this doesn’t mean you’ve delivered quality care. It means you’ve followed the cookbook formula to get your bonus. Conversely, just because you didn’t give an AMI patient an aspirin, this doesn’t mean you didn’t deliver high-quality care. It may mean that as a physician, you feel that giving aspirin to this particular AMI patient may not be in the patient’s best interest.

The Value of Autonomy

What do cochlear implants, the Epley maneuver, antibiotic therapy for peptic ulcers, and laparoscopic cholecystectomy have in common? These are just a few examples of deviations from clinical practice norms that resulted in major innovations and improvements in medical care. Although the above examples are well accepted in current medical practice, when they were introduced they were all initially rejected-and in some cases labeled malpractice by conventional medicine. One cannot deny the impact such practice deviations have had on the evolution of medical care to date. PQRI will enhance practice conformity at the expense of any deviation from practice norms that would result in similar innovations in the future. This is probably the worst and most insidious part of PQRI because we will never know what innovations would have occurred if not for such intrusion into the work of professionals.

Which brings me to the word professional. Part of the identity of a professional is the capacity for autonomous judgment and decision-making. If we are following a cookbook protocol, can we call ourselves professionals? And why should anyone pay for our services as professionals? Why not hire a technician who can follow the book as well as anyone else?

Voluntary?

Although the PQRI is a voluntary program, many see it as inevitably becoming mandatory at some point in the future. Consequently, they may ask, Why whine and complain about it? Although I, too, suspect that CMS plans to expand PQRI and probably make it mandatory, I do not see it as inevitable that all physicians should participate. Particularly, if physicians understand that (1) it will not result in improved payment, (2) it will not result in improved quality of care, and (3) it will result in the cookbooking of medical care, then aren’t we ethically required to reject it? CMS requires physician participation and acceptance of this program to make it work.

Tips from Medicare

PQRI reminds me of an incident that occurred during a college summer job. I was working as a waiter during the business lunch crowd shift. In came one of our regulars, who was a difficult customer and a very poor tipper. One of my colleagues waited on him. My friend cleaned the table at the end of the meal, and she was highly insulted by his very meager tip. She grabbed the few coins and ran after him into the parking lot. She came back with a mischievous grin on her face. She had told him, Excuse me, but you forgot this-and promptly gave him back his tip. So far, fewer than 16% of eligible professionals have attempted participation in the initial PQRI. The AMA survey suggests that only two-thirds of this group will continue to participate. The other third seems to be saying the same as my waitress friend. Though CMS plans to increase the bonus from 1.5% to 2% (roughly 33 cents per CPT code), we should tell them Thanks, but no thanks. Even a good waiter gets a 15% tip.

References

1. Gianoli GJ. A pay cut by any other name is still a pay cut. ENToday 2007;2(5):16.
2. Personal communication.
3. Glendinning D. AMA survey results: Medicare rated as poor performer during debut of pay-for-reporting. AMNews Nov. 17, 2008.
4. Lindenauer PK, Remurs D, Roman S, et al. Public reporting and pay for performance in hospital quality improvement. NEJM 2007;356(5):486-96.
5. Glickman SW, Ou FS, DeLong ER, et al. Pay for performance, quality of care, and outcomes in acute myocardial infarction. JAMA 2007;297(21):2373-80.
6. Werner RM, Bradlow ET. Relationship between Medicare’s hospital performance measures and mortality rates. JAMA 2006;296(22):2694-702.

©2009 The Triological Society