Since 2007, the Centers for Medicare and Medicaid Services’ (CMS) Physician Quality Reporting System (PQRS) has been in place for physicians and other health care providers participating in Medicare Part B Fee for Service. The program provides several pathways for eligible providers and group practices to report quality information about their patients, including submission of claims data, participation in a qualified PQRS registry, direct electronic health record (EHR) submission, and EHR submission through a data submission vendor (Table 1).
|Participation in the Physician Quality Reporting System (PQRS) program is required in 2015 to avoid payment adjustment in 2017.|
|Medical oncologists may feel that the PQRS program is not relevant to medical oncology practice, primarily because of the lack of specialty-specific measures for medical oncology.|
Quality reporting even on a small PQRS-sized scale can provide important feedback and internal benchmarking for medical oncology practices that, in turn, can lead to change that improves care.
The newest method of participation involves participation in a qualified clinical data registry (QCDR), which is a CMS-approved entity (e.g., a registry, certification board, or collaborative) that collects clinical data to foster improvement in the quality of patient care (Table 2). Quality measures are developed by various provider associations, quality groups, and CMS and vary from year to year. An oncology measure set was introduced in 2014. The program has recently added special pathways for participation for small-group reporting, large-group reporting, and accountable care organizations.
Individuals and group practices that have met the criteria for satisfactory submission of PQRS quality measures via one of the reporting mechanisms have qualified for and received incentive payments equal to 0.5%-2.0% of their total estimated Medicare Part B Physician Fee Schedule (PFS)–allowed charges for covered professional services furnished during that year. Beginning in 2016, eligible providers who do not satisfactorily report data on quality measures for covered professional services during the 2014 PQRS program year will be subject to a 2.0% payment downward adjustment to their Medicare PFS amount for services provided in 2016.
|PQRS 71||Breast cancer: Hormonal therapy for stage IC-IIIC estrogen receptor/progesterone receptor (ER/PR)-positive breast cancer (NQF 0387)|
|PQRS 72||Colon cancer: Chemotherapy for AJCC stage III colon cancer patients (NQF 0385)|
|PQRS 110||Preventive care and screening: Influenza immunization (NQF 0041)|
|PQRS 130||Documentation of current medications in the medical record (NQF 0419)|
|PQRS 143||Oncology: Medical and radiation—Pain intensity quantified (NQF 0384)|
|PQRS 144||Oncology: Medical and radiation—Plan of care for pain (NQF 0383)|
|PQRS 226||Preventive care and screening: Tobacco use: Screening and cessation intervention (NQF 0028)|
Medical Oncologists and PQRS
Some interesting specialty-specific data are provided in the March 2014 CMS 2012 Reporting Experience Including Trends (2007-2013) for PQRS and the Electronic Prescribing Incentive Program.1 The proportion of eligible oncology/hematology professionals participating in PQRS increased from 3,066 (28.2%) in 2009 to 6,163 (48.3%) in 2012. In 2012, most oncology/hematology professionals participated in PQRS via claims reporting (27.0% of those eligible) compared to 6.5% who participated via a registry mechanism, 2.5% who participated via EHR report, 2.1% who participated using measure groups via a registry mechanism, and 0.2% who participated using measure groups via claims reporting. In 2012, 5,391 oncology/hematology providers participated (87.5% of those eligible) but only 42.2% were incentive eligible, receiving payments ranging from a minimum of $0.11 to a maximum of $13,674 with a median of only $449.
The incentive eligibility rate was related to the mode of PQRS participation, with a high percentage of eligibility for providers using registries, measure groups/registries, and EHR reporting (95.2%, 96.2%, and 94.6%, respectively), and lower rates for measure groups/claims and claims-based reporting (75.0% and 68.7%, respectively). These relatively low participation rates and low incentive payment rates for medical oncologists suggest substantial barriers existed for participation as recently as 2012, with claims-based reporting being more challenging than registry-based reporting. For all providers, claims-based reporting was associated with high rates of inaccurate diagnosis code, procedure code, and age-range submissions.
Barriers to PQRS Reporting for Medical Oncologists
There are numerous potential barriers to PQRS participation for medical oncologists. Even in 2012, there may simply have been a lack of awareness about the program and how to participate. A substantial proportion of other medical specialties, subspecialties, and provider types have higher rates of participation in the program than medical oncologists.
To date, a substantial proportion of medical oncologists may feel that the program is not relevant to medical oncology practice, primarily because of the lack of specialty-specific measures for medical oncology. This may be addressed, in part, by the inclusion of the new oncology measure group for the 2014 data-collection year. Other perceived barriers possibly include the complexity of the overall program, the options for participation, the data submission requirements, and the lack of infrastructure needed to participate for small, medium, and large practices. There may also be competing priorities for quality-improvement projects, particularly those tied to pay for performance for non-Medicare payers. The relatively low rates of incentive payments combined with the relatively low payment amounts and the long lag time for payment and feedback may discourage potential medical oncology participants in the PQRS program.
|Core 2||Staging documented within 1 month of first office visit|
|Core 4a||Pain intensity quantified by second office visit (includes documentation of no pain)|
|Core 10||Chemotherapy intent (curative vs. non-curative) documented before or within
2 weeks after administration
|Core 13aa||Performance status documented prior to initiating chemotherapy|
|Core 13a1||Chemotherapy administered to patients with metastatic solid tumor with performance status of 3, 4, or undocumented (lower score, better)|
|Core 21a||Smoking status/tobacco use documented in past year|
|Core 25a||Documentation of patient’s advance directives by the third office visit|
|Core 25e||GCSF administered to patients who received chemotherapy for metastatic cancer (lower score–better)|
|Symptom 29a||Antiemetic therapy prescribed for highly emetogenic chemotherapy risk|
|Symptom 29c||Antiemetic therapy prescribed for moderately emetogenic chemotherapy risk|
|EOL 36a||Pain intensity quantified on either of the last two visits before death (includes documentation of no pain)|
|EOL 44a||Hospice enrollment and enrolled more than 3 days before death|
|EOL 47f||Location of death documented (*paired measure)|
|EOL 47c2||Death from cancer in intensive care unit (*paired measure)|
|EOL 48||Chemotherapy administered within last 2 weeks of life (lower score, better)|
|Breast 53||Combination chemotherapy received within 4 months of diagnosis by women under age 70 with AJCC stage IA (T1c) and IB to III ER- or PR-negative breast cancer|
|Breast 54||Test for HER2/neu overexpression or gene amplification|
|Breast 57||Trastuzumab received by patients with AJCC stage I (T1c) to III HER2/neu positive breast cancer|
|Breast 59||Tamoxifen or AI received within 1 year of diagnosis by patients with AJCC stage IA (T1c) and IB to III ER- or PR-positive breast cancer|
|Colorectal 68||Adjuvant chemotherapy received within 4 months of diagnosis by patients with AJCC stage III colon cancer|
With the impending transition in the program from financial incentives to financial penalties, a substantial increase in the proportion of medical oncology participants is anticipated for PQRS beginning in 2014. The penalties are set to be assessed in 2015, at a time when medical oncology practices are likely contending with the financial stressor of the ongoing Medicare sequester, and numerous other financial and workforce issues.
ASCO recently teamed up with one of the most popular registry vendors, CECity, to help members participate in PQRS at a discounted rate. A list of other popular registry vendors with services and pricing is available.1
PQRS program presents the following major drawbacks for medical oncologists from a quality-of-oncology-care perspective:
- The pathway to participation with the highest success rate in terms of incentive payments (measure group reporting via a registry) is also the pathway with the smallest sample size requirement: 20 patients. Although any substantial increase in this number will likely generate increased complaints about the burdens associated with program participation, data on only 20 patients seem unlikely to represent practice performance over each year of participation.
- Starting last year, there is now a 2-year gap between submission of measurement data and calculation of an adjustment or penalty. Data on at least one medical oncology measure demonstrated a substantial decrease in performance in a single year.1 In order for quality-improvement activities to be meaningful, more rapid turnaround and analysis of the data is necessary.
- The program is saddled with a complex process for participants to undertake in order to obtain performance data and feedback. Incentive payments arrive from CMS without any accompanying explanation. Reports are accessible via Individuals Authorized Access to the CMS Computer Services portal, but, in my experience, it is fraught with technical problems. I have participated since 2007 and have never successfully obtained any useful feedback on my performance. Detailed information about the feedback reports is provided in a CMS document.2
- The most effective pathways to successful participation to date are associated with the costs of using a commercial vendor, either for registry reporting or for large-group data submission, which have offset the declining incentive payments.1 Larger groups with higher success rates and claims reporting require a substantial amount of infrastructure for clean data submission.1 With the upcoming transition to penalty assessment only, participation in PQRS will result in significant costs for all participating practices.
- From a medical oncology quality perspective, a large number of measures included in the new oncology measure group have simplified and perfunctory content. Acknowledging the challenge of measure development and harmonization, it is difficult to imagine that practicing oncologists would view the highest-quality practices as performing well on only a handful of oncology measures, including cancer stage and medication reconciliation. Oncology PQRS participants and nonparticipants know that oncology care is complex, and these measures are far from that.
These drawbacks have led to a perceived lack of value for the PQRS program. In fact, it is being phased out and followed by several programs, including the Value-Based Payment Modifier, with even higher levels of complexity and steeper penalties than PQRS.
Why Bother to Participate Except to Avoid a Penalty?
The drawbacks in the PQRS program for medical oncologists lead to a crucial question: Is there any reason to participate in the remaining years of the PQRS program other than to avoid being penalized? For quality reporting–naive practices, PQRS participation represents an introduction to quality measurement. The bar is set very low in terms of data-submission requirements for individual physicians utilizing a measures group via registry. The commercially available software platforms, including the one engaged by ASCO, are relatively easy to use. Quality reporting at this level represents the tip of an iceberg: quality measurement is burgeoning and tied to essentially all new payment-reform models, making entry-level participation valuable. Even on a small PQRS-sized scale, quality reporting can provide important feedback and internal benchmarking for practices that, in turn, can lead to change that improves care. Several examples from my own solo breast cancer–dedicated practice support this notion.
After 1 year with a failed attempt at claims reporting (2007) resulting in no incentive payment, I began participating using measures group reporting via registry through several commercial vendors, most recently PQRSWizard. I chose the preventative care measures group, which includes Measure 39 (Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older). Over my subsequent years of participation, this measure guided my practice to focus on accurate history taking, documentation, and appropriate recommendations for osteoporosis, which has become increasingly important with the rise in the number of patients with breast cancer taking aromatase inhibitors.
Collecting data on Measure 113 (Colorectal Cancer Screening) heightened my awareness of colorectal cancer screening, which has become increasingly important as my population of patients who are breast cancer survivors has grown.
Collecting data on Measure 48 (Urinary Incontinence: Assessment of Presence of Absence of Urinary Incontinence in Women Aged 65 Years and Older) led to a heightened awareness of and increased referrals to local urologists in a substantial proportion of my patients.
Collecting data on Measure 173 (Preventive Care and Screening: Unhealthy Alcohol Use) led to a higher-than-anticipated number of positive screens in my patients, which prompted referrals for counseling. Alcohol use was always documented at the time of initial consultation but only infrequently during follow-up visits—PQRS participation changed that.
The Future for PQRS and Other Avenues for Quality Reporting
Statutes and regulations relating to the PQRS program are summarized on the CMS website. The Affordable Care Act authorized the incentives through 2014 and requires that penalties begin in 2015. An important change was made to the program at the end of the last fiscal year: the inclusion of Qualified Clinical Data Registries (QCDRs) as another pathway to PQRS participation. Importantly, QCDRs cover quality measures across multiple payers; they are not limited to Medicare beneficiaries. An appealing feature of QCDRs for oncology is that the registry can select non-PQRS measures for reporting.
Another significant difference is a requirement for public data reporting. QCDRs were included for the first time in the 2014 PFS Final Rule, and data for 2014 will be submitted in the first quarter of 2015. Fortunately for ASCO members participating in the Quality of Oncology Practice Initiative (QOPI®), ASCO’s flagship quality assessment and improvement program, QOPI has been recognized by CMS as a deemed registry. It is anticipated that the QOPI software platform will permit PQRS participation by the end of 2015. In addition to the requirement for some outcome measures that are more challenging than process measures, PQRS participation via QCDR will require data submission on a substantial number of patients (50% of applicable patients). This high requirement exceeds the current requirement for data abstraction for QOPI participation and ASCO is exploring ways to accept electronic data feeds into QOPI to facilitate this increased reporting requirement. While acknowledging the challenges of this option for PQRS participation, ASCO supports it because it will now become integrated into QOPI and other ASCO quality-improvement and payment-reform initiatives.
Medical oncologists need to be able to define and measure quality cancer care. PQRS reporting using the new oncology measure set is a small but critical step, as is the ability for oncologists to choose the quality measures for QCDR reporting. Taking the leap and participating in PQRS through QOPI as a CMS-approved registry is another.
About the Author: Dr. Hendricks runs a solo breast cancer practice in Bethesda, Maryland. She has been an ASCO member for 22 years and participated in ASCO’s Quality Training Program. Dr. Hendricks also serves on ASCO’s Quality of Care Committee, QOPI Certification Oversight Council, Government Relations Committee, and the Planning Committee for the ASCO Quality Care Symposium.