When Paul Storrs, M.D., delivered a recent presentation to members of the University of Illinois-Chicago’s dermatology department on the Centers for Medicare & Medicaid Services’ (CMS) new Physician Quality Reporting Initiative (PQRI), and what it entails for dermatologists, there were, as he puts it, “a lot of people rolling their eyes, as if to say: ‘sounds like more paperwork, and if we know the government, there is no way this will benefit us,’” says Dr. Storrs, an assistant professor of clinical dermatology. “Their fear, based on their past experiences with government initiatives,” he explains, is that whatever payoff might accrue from participating in the reporting program may be offset by the physician and staff time expended in participation.
Yet Dr. Storrs and American Academy of Dermatology (AAD) members who have steeped themselves in the program are advising colleagues to consider the big picture before they assume the worst. After all, PQRI, which officially debuts in July, is the first attempt to reward participation rather than punish noncompliance, some say, because it’s voluntary. And the potential reward, as the program is currently structured, could be substantial: Dermatologists who report performing three melanoma measures stand to receive an incentive bonus of 1.5% of total allowable CMS fee schedule charges for the period from July 1 to December 31, 2007, not just those related to melanoma.
What’s the Bottom Line?
“What Medicare is offering is a bonus payment of 1.5% not just on those particular (melanoma) visits, but on all eligible payments you bill for that 6-month period — regardless of the diagnosis,” explains Dirk Elston, M.D., chair of AAD’s P4P Workgroup and co-chair of the American Medical Association’s Workgroup, which have worked jointly on advising the government in structuring the program and setting the initial measures. Although there will be a payment cap — details are still being worked out, but dermatologists who saw and reported on only one melanoma patient during reporting period likely won’t receive the full amount, Dr. Elston notes — the potential incentive could be considerable nonetheless.
“If you have a reasonable number of patients for whom you’ve done this, and you receive the 1.5% on the psoriasis patients, for example, as well as melanoma patients, it’s really not a bad deal at all,” says Dr. Elston, director of dermatology at Geisinger Medical Center in Danville, PA, and a member of AAD’s clinical guidelines taskforce.
He also points to the relatively straightforward PQRI measures for dermatology — a total of three, all related to a single diagnosis — far fewer and far less complex than those being employed in general internal medicine. Basically, the program (see “PQRI for Dermatologists: The Basics” on page 50 for complete details) applies only to patients with melanoma or a history of melanoma, and involves three measures:
1. asking the patient about new or changing moles
2. performing a complete skin exam (genitalia excepted)
3. counseling the patient to perform a self-examination for new or changing moles.
“They’re very simple, basic measures — and they’re the right thing to do,” Dr. Elston says. By comparison, in internal medicine, more than 100 measures, covering a wide range of diagnoses, have been identified for inclusion.
“Of course, this is the first iteration of this program, and if dermatologists don’t want to participate or document these things, they don’t have to,” he adds. CMS begins collecting the reported data in July, via CMS 1500 claims forms using ICD-9 and CPT codes, and the newly devised “Category II” reporting codes, for the period through the end of 2007. (Providers were encouraged to begin reporting data from January 1, 2007, to work out potential software problems or bugs in the system before the PQRI program began in earnest.)
The program also has been structured to account for practical, logistical or other difficulties dermatologists may encounter in working with melanoma patients to report performance. Exception codes (P codes) have been developed to handle situations in which completing the measures may be either infeasible or inappropriate — for example, when a patient declines a total skin exam, or is blind and can’t perform self-examination.
Some Raise Concerns About Program’s Intent
Both Dr. Elston and Dr. Storrs acknowledge the concerns that dermatologists have raised about this program. The primary one is whether the data will be used to “profile” dermatologists in the manner that’s occurring in the private-payer sector.
“It appears that’s not the case, per what CMS has agreed to up front with the AMA,” Dr. Elston says. “Congress can do what it wants, but we haven’t seen anything pushing in the direction.”
The second question, more philosophical in nature and more difficult to answer, is whether the PQRI is truly about quality improvement. While detractors have stepped up to decry the initiative as a cleverly packaged antidote to the Medicare budget cutting that’s in store in the next few years, Dr. Elston urges dermatologists to at least realize that PQRI involves only diagnoses and measures chosen by the specialty societies. And those measures, he explains, are based on “existing, current vetted guidelines” of care that evolved from published evidence.
“They’re not pulling these things [measures] out of their hat,” he says. “The question becomes: Is standardized care better quality care? Not always, but standards of care are widely adopted by all specialty societies — and CMS didn’t tell us [dermatology] what we had to measure, just that we had to propose measures.” (CMS did make it clear, however, that it would choose measures if the specialties did not propose diagnoses and associated measures.)
A similarly structured incentive plan under development by America’s Health Insurance Plans (AHIP) for meeting “high-bar quality measures,” in contrast, would pay substantial incentives to participants, yet categorize non-participants in a negative light, as “second-tier physicians,” he explains. The scheme proposed also would require health plan members to pay an associated higher co-payment for choosing non-participating physicians, who would be deemed in Explanation of Benefit (EOB) statements as “low quality,” Dr. Elston says, or described as “a physician who doesn’t consider quality. None of the proposed wording options sounded particularly flattering.” He notes that the AHIP program is hardly imminent, as the insurers “don’t even know how they’ll capture data at this point.”
At least the CMS plan appears to be well intentioned, and is at present completely voluntary in nature, observers claim.
“The thing that has been stressed about PQRI is that, as opposed to previous attempts to cut budgets or use capitation [methodologies] to reduce costs, this is actually an attempt to reward physicians for better performance, vis-à-vis better patient care,” Dr. Storrs says. “And this could be huge for dermatologists because melanoma, while it’s a big issue in that it’s life-threatening, typically accounts for only a small percentage of the total patients we see.” CMS has indicated that the exact payments — and the structure of any associated cap — have yet to be finalized. The agency is expected to provide initial clarification in August 2007, with finalization to follow in November.
“The thing we all need to keep in mind is that this movement — pay for performance, or pay for reporting — is a hot button right now, and it’s not going to go away,” says Dr. Storrs.
What Will the Future Hold?
What remains to be seen as well is how long the “simple” reporting measures will remain, before the bar is raised and the reporting arena broadened. Dr. Elston reminds dermatologists that the “H&P elements” in two of the three CMS PQRI melanoma measures are “something most dermatologists already do” and that CMS is unlikely to continue to “pay extra for something they’re already paying for in E&M [Evaluation & Management] codes. These current [reporting] measures may survive into 2008, but I doubt that they will survive further — they just aren’t ‘high-bar’ enough measures,” he says. Both he and Dr. Storrs also urged dermatologists to expect more measures, identified by the field and proposed to CMS — likely in such major outcomes-related areas where wide variations in practice and standards of care exist. Those might include, for example, measures intended to reduce or prevent prednisone-induced osteoporosis, or to ensure correct classification and treatment of diabetes-associated leg ulcers.
“They [CMS] are looking for things [measures] that will, at the end of this, improve public health,” Dr. Elston says. “But as with any program like this, there will be bumps along the road and things that aren’t applied as intended. That’s why the AAD, AMA and other specialties need to stay involved.”
When Paul Storrs, M.D., delivered a recent presentation to members of the University of Illinois-Chicago’s dermatology department on the Centers for Medicare & Medicaid Services’ (CMS) new Physician Quality Reporting Initiative (PQRI), and what it entails for dermatologists, there were, as he puts it, “a lot of people rolling their eyes, as if to say: ‘sounds like more paperwork, and if we know the government, there is no way this will benefit us,’” says Dr. Storrs, an assistant professor of clinical dermatology. “Their fear, based on their past experiences with government initiatives,” he explains, is that whatever payoff might accrue from participating in the reporting program may be offset by the physician and staff time expended in participation.
Yet Dr. Storrs and American Academy of Dermatology (AAD) members who have steeped themselves in the program are advising colleagues to consider the big picture before they assume the worst. After all, PQRI, which officially debuts in July, is the first attempt to reward participation rather than punish noncompliance, some say, because it’s voluntary. And the potential reward, as the program is currently structured, could be substantial: Dermatologists who report performing three melanoma measures stand to receive an incentive bonus of 1.5% of total allowable CMS fee schedule charges for the period from July 1 to December 31, 2007, not just those related to melanoma.
What’s the Bottom Line?
“What Medicare is offering is a bonus payment of 1.5% not just on those particular (melanoma) visits, but on all eligible payments you bill for that 6-month period — regardless of the diagnosis,” explains Dirk Elston, M.D., chair of AAD’s P4P Workgroup and co-chair of the American Medical Association’s Workgroup, which have worked jointly on advising the government in structuring the program and setting the initial measures. Although there will be a payment cap — details are still being worked out, but dermatologists who saw and reported on only one melanoma patient during reporting period likely won’t receive the full amount, Dr. Elston notes — the potential incentive could be considerable nonetheless.
“If you have a reasonable number of patients for whom you’ve done this, and you receive the 1.5% on the psoriasis patients, for example, as well as melanoma patients, it’s really not a bad deal at all,” says Dr. Elston, director of dermatology at Geisinger Medical Center in Danville, PA, and a member of AAD’s clinical guidelines taskforce.
He also points to the relatively straightforward PQRI measures for dermatology — a total of three, all related to a single diagnosis — far fewer and far less complex than those being employed in general internal medicine. Basically, the program (see “PQRI for Dermatologists: The Basics” on page 50 for complete details) applies only to patients with melanoma or a history of melanoma, and involves three measures:
1. asking the patient about new or changing moles
2. performing a complete skin exam (genitalia excepted)
3. counseling the patient to perform a self-examination for new or changing moles.
“They’re very simple, basic measures — and they’re the right thing to do,” Dr. Elston says. By comparison, in internal medicine, more than 100 measures, covering a wide range of diagnoses, have been identified for inclusion.
“Of course, this is the first iteration of this program, and if dermatologists don’t want to participate or document these things, they don’t have to,” he adds. CMS begins collecting the reported data in July, via CMS 1500 claims forms using ICD-9 and CPT codes, and the newly devised “Category II” reporting codes, for the period through the end of 2007. (Providers were encouraged to begin reporting data from January 1, 2007, to work out potential software problems or bugs in the system before the PQRI program began in earnest.)
The program also has been structured to account for practical, logistical or other difficulties dermatologists may encounter in working with melanoma patients to report performance. Exception codes (P codes) have been developed to handle situations in which completing the measures may be either infeasible or inappropriate — for example, when a patient declines a total skin exam, or is blind and can’t perform self-examination.
Some Raise Concerns About Program’s Intent
Both Dr. Elston and Dr. Storrs acknowledge the concerns that dermatologists have raised about this program. The primary one is whether the data will be used to “profile” dermatologists in the manner that’s occurring in the private-payer sector.
“It appears that’s not the case, per what CMS has agreed to up front with the AMA,” Dr. Elston says. “Congress can do what it wants, but we haven’t seen anything pushing in the direction.”
The second question, more philosophical in nature and more difficult to answer, is whether the PQRI is truly about quality improvement. While detractors have stepped up to decry the initiative as a cleverly packaged antidote to the Medicare budget cutting that’s in store in the next few years, Dr. Elston urges dermatologists to at least realize that PQRI involves only diagnoses and measures chosen by the specialty societies. And those measures, he explains, are based on “existing, current vetted guidelines” of care that evolved from published evidence.
“They’re not pulling these things [measures] out of their hat,” he says. “The question becomes: Is standardized care better quality care? Not always, but standards of care are widely adopted by all specialty societies — and CMS didn’t tell us [dermatology] what we had to measure, just that we had to propose measures.” (CMS did make it clear, however, that it would choose measures if the specialties did not propose diagnoses and associated measures.)
A similarly structured incentive plan under development by America’s Health Insurance Plans (AHIP) for meeting “high-bar quality measures,” in contrast, would pay substantial incentives to participants, yet categorize non-participants in a negative light, as “second-tier physicians,” he explains. The scheme proposed also would require health plan members to pay an associated higher co-payment for choosing non-participating physicians, who would be deemed in Explanation of Benefit (EOB) statements as “low quality,” Dr. Elston says, or described as “a physician who doesn’t consider quality. None of the proposed wording options sounded particularly flattering.” He notes that the AHIP program is hardly imminent, as the insurers “don’t even know how they’ll capture data at this point.”
At least the CMS plan appears to be well intentioned, and is at present completely voluntary in nature, observers claim.
“The thing that has been stressed about PQRI is that, as opposed to previous attempts to cut budgets or use capitation [methodologies] to reduce costs, this is actually an attempt to reward physicians for better performance, vis-à-vis better patient care,” Dr. Storrs says. “And this could be huge for dermatologists because melanoma, while it’s a big issue in that it’s life-threatening, typically accounts for only a small percentage of the total patients we see.” CMS has indicated that the exact payments — and the structure of any associated cap — have yet to be finalized. The agency is expected to provide initial clarification in August 2007, with finalization to follow in November.
“The thing we all need to keep in mind is that this movement — pay for performance, or pay for reporting — is a hot button right now, and it’s not going to go away,” says Dr. Storrs.
What Will the Future Hold?
What remains to be seen as well is how long the “simple” reporting measures will remain, before the bar is raised and the reporting arena broadened. Dr. Elston reminds dermatologists that the “H&P elements” in two of the three CMS PQRI melanoma measures are “something most dermatologists already do” and that CMS is unlikely to continue to “pay extra for something they’re already paying for in E&M [Evaluation & Management] codes. These current [reporting] measures may survive into 2008, but I doubt that they will survive further — they just aren’t ‘high-bar’ enough measures,” he says. Both he and Dr. Storrs also urged dermatologists to expect more measures, identified by the field and proposed to CMS — likely in such major outcomes-related areas where wide variations in practice and standards of care exist. Those might include, for example, measures intended to reduce or prevent prednisone-induced osteoporosis, or to ensure correct classification and treatment of diabetes-associated leg ulcers.
“They [CMS] are looking for things [measures] that will, at the end of this, improve public health,” Dr. Elston says. “But as with any program like this, there will be bumps along the road and things that aren’t applied as intended. That’s why the AAD, AMA and other specialties need to stay involved.”
When Paul Storrs, M.D., delivered a recent presentation to members of the University of Illinois-Chicago’s dermatology department on the Centers for Medicare & Medicaid Services’ (CMS) new Physician Quality Reporting Initiative (PQRI), and what it entails for dermatologists, there were, as he puts it, “a lot of people rolling their eyes, as if to say: ‘sounds like more paperwork, and if we know the government, there is no way this will benefit us,’” says Dr. Storrs, an assistant professor of clinical dermatology. “Their fear, based on their past experiences with government initiatives,” he explains, is that whatever payoff might accrue from participating in the reporting program may be offset by the physician and staff time expended in participation.
Yet Dr. Storrs and American Academy of Dermatology (AAD) members who have steeped themselves in the program are advising colleagues to consider the big picture before they assume the worst. After all, PQRI, which officially debuts in July, is the first attempt to reward participation rather than punish noncompliance, some say, because it’s voluntary. And the potential reward, as the program is currently structured, could be substantial: Dermatologists who report performing three melanoma measures stand to receive an incentive bonus of 1.5% of total allowable CMS fee schedule charges for the period from July 1 to December 31, 2007, not just those related to melanoma.
What’s the Bottom Line?
“What Medicare is offering is a bonus payment of 1.5% not just on those particular (melanoma) visits, but on all eligible payments you bill for that 6-month period — regardless of the diagnosis,” explains Dirk Elston, M.D., chair of AAD’s P4P Workgroup and co-chair of the American Medical Association’s Workgroup, which have worked jointly on advising the government in structuring the program and setting the initial measures. Although there will be a payment cap — details are still being worked out, but dermatologists who saw and reported on only one melanoma patient during reporting period likely won’t receive the full amount, Dr. Elston notes — the potential incentive could be considerable nonetheless.
“If you have a reasonable number of patients for whom you’ve done this, and you receive the 1.5% on the psoriasis patients, for example, as well as melanoma patients, it’s really not a bad deal at all,” says Dr. Elston, director of dermatology at Geisinger Medical Center in Danville, PA, and a member of AAD’s clinical guidelines taskforce.
He also points to the relatively straightforward PQRI measures for dermatology — a total of three, all related to a single diagnosis — far fewer and far less complex than those being employed in general internal medicine. Basically, the program (see “PQRI for Dermatologists: The Basics” on page 50 for complete details) applies only to patients with melanoma or a history of melanoma, and involves three measures:
1. asking the patient about new or changing moles
2. performing a complete skin exam (genitalia excepted)
3. counseling the patient to perform a self-examination for new or changing moles.
“They’re very simple, basic measures — and they’re the right thing to do,” Dr. Elston says. By comparison, in internal medicine, more than 100 measures, covering a wide range of diagnoses, have been identified for inclusion.
“Of course, this is the first iteration of this program, and if dermatologists don’t want to participate or document these things, they don’t have to,” he adds. CMS begins collecting the reported data in July, via CMS 1500 claims forms using ICD-9 and CPT codes, and the newly devised “Category II” reporting codes, for the period through the end of 2007. (Providers were encouraged to begin reporting data from January 1, 2007, to work out potential software problems or bugs in the system before the PQRI program began in earnest.)
The program also has been structured to account for practical, logistical or other difficulties dermatologists may encounter in working with melanoma patients to report performance. Exception codes (P codes) have been developed to handle situations in which completing the measures may be either infeasible or inappropriate — for example, when a patient declines a total skin exam, or is blind and can’t perform self-examination.
Some Raise Concerns About Program’s Intent
Both Dr. Elston and Dr. Storrs acknowledge the concerns that dermatologists have raised about this program. The primary one is whether the data will be used to “profile” dermatologists in the manner that’s occurring in the private-payer sector.
“It appears that’s not the case, per what CMS has agreed to up front with the AMA,” Dr. Elston says. “Congress can do what it wants, but we haven’t seen anything pushing in the direction.”
The second question, more philosophical in nature and more difficult to answer, is whether the PQRI is truly about quality improvement. While detractors have stepped up to decry the initiative as a cleverly packaged antidote to the Medicare budget cutting that’s in store in the next few years, Dr. Elston urges dermatologists to at least realize that PQRI involves only diagnoses and measures chosen by the specialty societies. And those measures, he explains, are based on “existing, current vetted guidelines” of care that evolved from published evidence.
“They’re not pulling these things [measures] out of their hat,” he says. “The question becomes: Is standardized care better quality care? Not always, but standards of care are widely adopted by all specialty societies — and CMS didn’t tell us [dermatology] what we had to measure, just that we had to propose measures.” (CMS did make it clear, however, that it would choose measures if the specialties did not propose diagnoses and associated measures.)
A similarly structured incentive plan under development by America’s Health Insurance Plans (AHIP) for meeting “high-bar quality measures,” in contrast, would pay substantial incentives to participants, yet categorize non-participants in a negative light, as “second-tier physicians,” he explains. The scheme proposed also would require health plan members to pay an associated higher co-payment for choosing non-participating physicians, who would be deemed in Explanation of Benefit (EOB) statements as “low quality,” Dr. Elston says, or described as “a physician who doesn’t consider quality. None of the proposed wording options sounded particularly flattering.” He notes that the AHIP program is hardly imminent, as the insurers “don’t even know how they’ll capture data at this point.”
At least the CMS plan appears to be well intentioned, and is at present completely voluntary in nature, observers claim.
“The thing that has been stressed about PQRI is that, as opposed to previous attempts to cut budgets or use capitation [methodologies] to reduce costs, this is actually an attempt to reward physicians for better performance, vis-à-vis better patient care,” Dr. Storrs says. “And this could be huge for dermatologists because melanoma, while it’s a big issue in that it’s life-threatening, typically accounts for only a small percentage of the total patients we see.” CMS has indicated that the exact payments — and the structure of any associated cap — have yet to be finalized. The agency is expected to provide initial clarification in August 2007, with finalization to follow in November.
“The thing we all need to keep in mind is that this movement — pay for performance, or pay for reporting — is a hot button right now, and it’s not going to go away,” says Dr. Storrs.
What Will the Future Hold?
What remains to be seen as well is how long the “simple” reporting measures will remain, before the bar is raised and the reporting arena broadened. Dr. Elston reminds dermatologists that the “H&P elements” in two of the three CMS PQRI melanoma measures are “something most dermatologists already do” and that CMS is unlikely to continue to “pay extra for something they’re already paying for in E&M [Evaluation & Management] codes. These current [reporting] measures may survive into 2008, but I doubt that they will survive further — they just aren’t ‘high-bar’ enough measures,” he says. Both he and Dr. Storrs also urged dermatologists to expect more measures, identified by the field and proposed to CMS — likely in such major outcomes-related areas where wide variations in practice and standards of care exist. Those might include, for example, measures intended to reduce or prevent prednisone-induced osteoporosis, or to ensure correct classification and treatment of diabetes-associated leg ulcers.
“They [CMS] are looking for things [measures] that will, at the end of this, improve public health,” Dr. Elston says. “But as with any program like this, there will be bumps along the road and things that aren’t applied as intended. That’s why the AAD, AMA and other specialties need to stay involved.”
