Is Participating in the Medicare PQRI Worthwhile?
From the Health and Human Services website:
“The 2006 Tax Relief and Health Care Act (TRHCA) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries during the second half of 2007 (the 2007 reporting period). CMS named this program the Physician Quality Reporting Initiative (PQRI). The PQRI was further modified as a result of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) and the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) In 2011, the program name was changed to Physician Quality Reporting System (Physician Quality Reporting).”
In an effort to cut Medicare costs and improve the quality of patient care Congress included a provision which made participation in PQRI mandatory, beginning in 2015, in the Patient Protection and Affordable Care Act (PPAC, AKA the Healthcare Reform Bill). Beginning is 2016 Medicare will decrease Medicare reimbursement by 2% to healthcare providers who do not participate in the program. Currently Medicare is paying bonuses of 0.5% to healthcare providers who participate in PQRI as an incentive to get healthcare providers to participate in the program.
The goal of the Medicare PQRI is to have healthcare providers report treatment programs and the outcome of the treatment so that a data base can be established as to which treatments are most effective and least costly. The sad truth in the practice of medicine is that there are very few reliable studies which evaluate the effectiveness of medical treatment protocols. Most doctors prescribe the treatment that they feel most comfortable with, or that maybe was successful for them early in their career. I have heard, from several different sources, that one third of the information that doctors learn in medical school is obsolete within 3 years, but most doctors don’t know which third it is that becomes obsolete. Whether this is true or not, the point is that we often don’t know which treatment protocols are most effective.
While to goal of the Medicare PQRI is laudable, the question is: Is the program effective? So far, the results have been marginable at best. Because of the minimal incentives to participate in the program, the time involved in the implementation of the program, the minimal participation in the program, and poor response by the CMS (Centers for Medicare and Medicaid Services) the participation by doctors has been small and the results have not been what Congress anticipated.
I don’t know of one treatment protocol that has been adopted or discontinued because of the PQRI. I don’t know if one treatment program has been promoted over another because of PQRI. To be fair, the length of time that the program has been in affect has been short, but we are talking about a government program, so the results may be not be known for some time. Let’s give the program a couple of years (and millions of dollars) before we judge the effectiveness of the program.
Beside the 2% reduction in reimbursement to doctors who do not participate in PQRI, CMS will publish participating and non-participating PQRI doctors on its website. Whether patients will care if their doctor participates or not, CMS believes this information is important for patients to know. The CMS also has a form letter which it sends out to Medicare patients explaining that participating in PQRI will not cost the patient any additional money.
In my opinion, the main purpose of PQRI is to condition patients to the fact that medical treatment will be rationed and treatment will often be the least costly one available. A by product of PQRI may be to find the most effective treatment available, but never before has the government been interested in the most effective way of doing anything. Let’s just say I have my doubts about this program, based on who initiated it, and who ultimately benefits from it. The program is aimed at helping patients and doctors, but, as is often the case with government programs, there are unintended consequences. Let’s hope this program saves lives and doesn’t cost lives. By promoting the least expensive treatment, and not the best treatment for patients, the later case may be the result.
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Tuesday, 11 October 2011
posted by Richard marotto
Where can you see the requirements and possibly sign up?
Wednesday, 29 June 2011
posted by r.oconner
I would strongly suggest to Dr's to not participate. If CMS audits your records, they will deny either most or all of your treatment as not "medically necessary" in which case you will have to pay back all the money. It doesn't matter how perfect your records are in meeting CMS guide lines, they are paying these reviewers to say no. The nurse who reviewed my records finally admitted that her review criteria were not what was published by CMS!!! Since I didn't participate I didn't have to refund.
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