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Will PQRS Affect Quality Care?

April 15, 2014

PQRS incentiveThe Physician Quality Reporting System (PQRS) is changing the face of providing patient care and revenue levels. Although this pay-for-performance initiative was introduced by the Centers for Medicare and Medicaid Services (CMS), there are indications that private healthcare payers may also adopt PQRS in the future. Physicians and other critics believe the industry is morphing from a fee-for-service system into a pay-for-performance platform. While this may be the obvious intent of the CMS regulations, private payers apparently are looking favorably on PQRS features.

PQRS submissions have resulted in around $26 million quality reporting incentives since inception. CMS reports that participation in PQRS is increasing with an estimated 280,000 eligible professionals (EPs) enrolled through April 2013.

Participation Growth Slow

The growth of participants, however, remains “slower” than CMS hoped. Observers, healthcare consultants and many physicians seem to agree there is one overriding reason for this modest growth: The documentation burden on medical practices. Yet, there may be some other contributing factors, when combined with the reporting burdens.

  • The general dissatisfaction with a pay-for-performance model,
  • The bonus incentives, two percent, may be insufficient to stimulate providers to adopt PQRS,
  • Although many providers agree that the healthcare system needs revamping, some veteran physicians may feel the way they’ve delivered patient services ensures quality care, regardless of providing additional evidence to CMS.

When combined with documentation mandates and the push by the Affordable Care Act (ACA) to implement pay-for-performance, many EPs consider the risk, cost and extra work as not matching the reward. The ACA 1.5 percent reimbursement penalty for insufficient reporting only adds to the dissatisfaction and also may be slowing PQRS participant growth.

Affect on Quality Patient Care

The intent of PQRS is noble: Improve patient care, while lowering or better controlling costs. There is little disagreement with the goal.

However, this also begs the question, “How can I deliver higher quality care at lower cost?” The dissatisfaction comes with the lack of workable answers by the medical community, to date.

Many providers believe the documentation needed to provide evidence to CMS of quality diagnosis and treatment activities to be a disincentive to even seeing as many patients as in the past. The requirement of recording actions that CMS considers incontrovertible proof of quality care delivery takes physicians extra time to note, resulting in more staff time to prepare accurate claims submissions.

Experts recommend the physician or practice manager install an “accuracy review” procedure to catch errors before submitting claims. Providers maintain this adds even more non-care delivery time to their day and/or more, not less, cost to practice operations.

While most EPs would love to improve or maintain the quality care they deliver, many simply find the challenge of documenting every nuance of diagnosis and treatment methodology as a detractor from controlling costs. It is difficult to forcefully argue with their position so far.

Those who are optimistic that, over time, EPs will develop reporting systems that satisfy PQRS requirements tend to remain unsure of how to do so. However, providers often believe the melding of bureaucracy (CMS) with quality patient care may be an unworkable marriage.

The Future

Should private payers install PQRS or similar pay-for-performance requirements, might physicians face even greater challenges? Many providers believe the answer to be “Yes.” Is this just negativity, resistance to change or veteran providers being “set in their ways?”

Or, is it the thoughtful analysis of documentation requirements that detract from quality patient care delivery for less than desired reward? The medical community and CMS are unsure of the true answer. As long as the passionate debate continues, there will be divergent supporters and critics of PQRS—and its requirements.

Patients, providers and observers should stay tuned for future developments.


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