The rate of surgical procedures is increasing annually, with more than 53 million outpatient procedures performed in the United States in 2010.
Ambulatory anesthesia has been the fastest growing segment of the specialty for more than a decade, and this trend shows no signs of abating. The steady advance of minimally invasive surgical techniques combined with the ability of anesthesia professionals to safely deliver precise, short-acting anesthetics has enabled us to get our patients home faster and healthier than ever before.
At the same time, the relentless march of Pay for Performance (P4P) in Washington, D.C. has increased the burden of regulatory reporting for all physicians, including physician anesthesiologists working in outpatient facilities. Each year, an increasing percentage of payments from Medicare will be contingent on successful reporting of quality measures for every anesthetic. The original Physician Quality Reporting System (PQRS) program, now more than five years old, was created to encourage physicians to report performance on one or more established measures. Through 2014, CMS offered small incentives to report. For example, in 2014 physicians reporting successfully will receive a bonus payment from CMS equal to 0.5 percent of their Medicare Billing for the year. Beginning in 2015, however, the PQRS bonus changes to a 'payment adjustment' or penalty of negative two percent of reimbursements for those who are not successfully reporting.
The Value Modifier (VM) system is a new program, which overlaps and expands on PQRS. In 2016, CMS will assess physician performance data from 2014. Eligible Performers (EPs) not reporting their performance will be penalized; those who do not report successfully will be eligible for incentive payments under a complex formula designed to redistribute money from worse performers to better ones. Successful VM reporting requires nine measures, from three different domains of the National Quality Strategy (NQS), including one outcome measure.
PQRS and VM use the same set of CMS-approved measures. Most of these are derived from a larger set of measures collected and endorsed by the National Quality Forum (NQF) , set up as a public-private partnership a decade ago specifically for this purpose. The process of creating a measure, validating it, and achieving NQF endorsement and CMS inclusion can take years of work. Most medical specialties – including anesthesiology – do not have enough measures approved by CMS for the average clinician to meet the new nine measure requirement of the VM system. This is especially true for outpatient providers, since many of the existing measures are for ‘high-end’ surgeries and patients.
At present, most providers report to CMS through the "claims based" mechanism, but this approach is being slowly phased out. In 2015 any group of more than 10 providers will be required to report through a group-reporting registry. Medicare plans for the future can be glimpsed in existing regulations, in comments by officials and in legislation being debated in Congress. First, it is clear that P4P will not go away. A steadily increasing percentage of every physician’s reimbursement from the federal government — which is about one-third of all anesthesia practice income, on average — will be linked to documentation of compliance with performance measures, and will be publicly reported. In 2015, this is a two percent risk — or $2,000per year for most anesthesia practitioners — but the planned evolution of PQRS and VM will bring this to about 10 percent by 2020. It is likely that where CMS leads, the entire fee-for-service universe will soon follow; PQRS requirements have already been extended to some state Medicaid programs and private insurers will likely soon follow suit.
In 2014, the Qualified Clinical Data Registry (QCDR) was introduced as a new mechanism for reporting physician performance to CMS. This new mechanism allows EPs to meet emerging requirements for PQRS and VM reporting. Under the QCDR, EPs contributing data to a clinical registry can get credit for meeting the requirements. The current QCDR reporting regulations state that an EP may be eligible for payment incentives if they report nine measures across three NQS domains. The difference under the new system is that a QCDR can use specialty-specific measures drawn from outside the existing pool approved by CMS. These 'non-PQRS measures' can be from any credible source, and must be clearly defined, publicly transparent and valid for the stated purpose. One of these measures reported on must be an outcomes measure. With the QCDR option available through the National Anesthesia Outcomes Registry (NACOR), anesthesia practices gained the ability to submit data on up to 19 anesthesia-related measures developed by the American Society of Anesthesiologists® (ASA) and the Anesthesia Quality Institute (AQI). These 19 measures approved for submission through NACOR include eight PQRS measures and 11 non-PQRS measures. Specifics are available on the AQI website at www.aqihq.org/pqrs.
AQI was designated as a QCDR in April 2014. AQI is the only anesthesia QCDR to be approved and was among one of the first 40 registries to be designated. To be certified, a QCDR must have experience in collecting performance data from multiple physicians in multiple different locations and practices must already be providing participants with risk-adjusted benchmarking information for quality management and must have appropriate safeguards in place for secure handling of protected healthcare information. NACOR met all of these requirements.
Federal officials believe that physician participation in clinical registries, with regular public benchmarking, is an important tool to achieve the Triple Aim of improved outcomes, improved efficiency and improved patient experience. The QCDR approach also relieves CMS of much of the burden of collecting, cleaning and scoring performance data from individual providers.
QCDR submission of performance data to CMS is available to any EP in a practice which is contributing data to NACOR. Participation in NACOR is on a per-group basis at a fee of $1,000 per attending physician anesthesiologist or independently-practicing nurse anesthetist. This fee is discounted to $0 for ASA members; most practices therefore participate in NACOR at no cost, as a benefit of ASA membership. QCDR reporting to CMS will be available at no additional cost to ASA members and for $295 per year to non-member EPs, with discounts available to large groups. To meet PQRS and VM requirements through the QCDR, practices must self-nominate to CMS, must complete waivers, and submit NPI numbers for each EP to AQI, must collect and code primary measure information in their electronic systems (either billing or medical record) and must transmit this information to NACOR as part of their regular data contribution.
The requirement for data reporting is not going to go away anytime soon. It’s time for providers to dive into the alphabet soup, get on board and avoid the payment penalties of the future.
