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The American Journal of Accountable Care March 2016
Cognitive Impairment and Reduced Early Readmissions in Congestive Heart Failure?
Mark W. Ketterer, PhD; Jennifer Peltzer, PsyD; Usamah Mossallam, MD; Cathy Draus, RN; John Schairer, DO; Bobak Rabbani, MD; Khaled Nour, MD; Gayathri Iyer, MD; Michael Hudson, MD; and James McCord, MD
Health Plan—Provider Accountable Care Partnerships: How Have They Evolved?
Aparna Higgins, MA; Kristin Stewart, MHSA; Grant Picarillo, MS; Nicole Brainard, PhD, MPH; and Kirstin Dawson, MS
Inpatient and 90-Day Postdischarge Outcomes in Cardiac Surgery
Donald E. Fry, MD; Michael Pine, MD, MBA; Susan M. Nedza, MD, MBA; David G. Locke, BS; Agnes M. Reband, BS; and Gregory Pine, BA
Will Regional Differences in Family Practice Procedures Impact Reimbursement Rates? A National Study of Medicare Part B
Man Hung, PhD; Jerry Bounsanga, BS; Anthony B. Crum, BS; and Maren W. Voss, MS
Employer-Led Efforts to Improve the Value of Health Spending
Megan McHugh, PhD; Claude R. Maechling, PhD; Dorothy D. Dunlop, PhD; Linda O’Dwyer, MSLIS, MA; Dustin D. French, PhD; Rahul K. Khare, MD, MS; Anna P. Nannicelli, MPH, MSW; Alexandra R. Brown, BA; a
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Currently Reading
Top 10 Ways to Improve Your Physician Quality Reporting System/Group Practice Reporting Option
Amy Holm, MHA, and Hymin Zucker, MD

Top 10 Ways to Improve Your Physician Quality Reporting System/Group Practice Reporting Option

Amy Holm, MHA, and Hymin Zucker, MD
PQRS and GPRO encompass patient experience, chronic condition management, and population health arenas so that physician reimbursement can be tied to performance. The authors describe how to accurately improve your quality metrics.
In April 2015, President Obama signed the Sustainable Growth Rate (SGR) formula repeal legislation. Originally, the SGR was calculated by linking Medicare expenses to economic growth, and Congress simply passed “doc fixes” to keep Medicare reimbursement at a steady rate.1 The new legislation, on the other hand, has changed the payment methodology entirely; beginning in 2019, physician payment will be tied to value-based payment structures.1

Whether physicians join an alternative payment model (APM) or get placed into a Merit-Based Incentive Payment System (MIPS), they will have to complete the Physician Quality Reporting System (PQRS) or the Group Practice Reporting Option (GPRO). Both are quality metrics submitted to the government, which encompass patient experience, chronic condition management, and population health arenas so that reimbursement can be tied to performance.2 The only difference between the quality metric programs is that when physicians are in an APM like an accountable care organization, they report as one entity via GPRO rather than individually reporting via PQRS.2 If a physician is reporting PQRS the results will dictate the physicians’ fee schedule for the subsequent year.2 If physicians are reporting GPRO, then the portion of shared savings attained will be adjusted based on the overall metric reporting.Since this reporting is universal for Medicare providers, it would be of best interest to adopt processes that will guarantee the highest possible quality outcomes to receive increased payment. Listed below are 10 proactive ways to accurately improve your PQRS/GPRO in an effort to succeed in the value-/merit-based world:
1. Obtain Your Quality and Resource Use Reports
Since 2014, every Medicare-paid physician has a Quality and Resource Use Report (QRUR) that can be accessed by their Taxpayer Identification Number (TIN) through the Provider Enrollment, Chain, and Ownership System (PECOS).3 This is how the CMS ranks a physician’s performance against other physicians in the market. The value modifier that dictates how independent physicians are paid is determined by measuring performance quality indicators (PQI) for up to 6 quality and 2 cost domains via claims data, then computing benchmarks for quality and cost based on prior-year performance, standardizing the performance scores, calculating composite scores for average TIN performance, and then categorizing the TIN by performance as high, average, or low.4

In order to succeed, one must know which category they are in so as to make the proper fixes either in quality and/or cost/utilization measures, as necessary. Once a physician is aware of their performance, as viewed by the government, they must begin to change their work flow and processes in an effort to keep the fee schedule positive. The QRUR may prove to be disheartening to many since it is scored on a curve, which, by definition, means that it is rare for a physician to be one deviation away from the mean. In an effort to reawaken the competitive nature that exists within each physician, administration and physicians should obtain and interpret these reports. Tierney et al discuss how data transparency to physicians can dramatically change their behavior for example, when physicians are shown the actual price of the labs they are the ordering, they tend to order fewer than when the cost is undisclosed.5 The QRUR is a first step in the creation of transparency.
2. Decide If You Would Do Best in MIPS or APMs Because of Value-Based Modification in 2017
MIPS is similar to the old fee-for service payment structure, except the government is going to gradually adjust the reimbursement based on the physician’s quality scores, meaningful use attainment (relating to use of electronic health records), and practice efficiency and improvement. Improvement will be measured either against the physicians’ previous years’ performance or against the performance of the physicians’ peers. By 2019, physicians enrolled in MIPS can experience a payment range from a down swing of 3.5x% to an upswing of 4.5x%, which will incrementally increase to ±9x% by 2022.6

If a physician chooses to get paid by an APM (like an accountable care organization [ACO]), they will be entitled to the highest possible reimbursement. An automatic 5% bonus will be added to the fee schedule just for being in an APM, and an additional upswing can be added if the practice is a certified patient-centered medical home. Since this model has the potential for the higher reimbursement, it also has the largest risk because earned shared savings will not be returned if metric standards are not met and even if they are met, if it is not 100%, then the ACO will receive a portion relative to the quality score.6

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