Fact Sheets

CHANGES TO THE PHYSICIAN QUALITY REPORTING INITIATIVE AND THE ELECTRONIC PRESCRIBING INCENTIVE PROGRAM

(INCLUDED IN THE CALENDAR YEAR 2011 MEDICARE PHYSICIAN FEE SCHEDULE PROPOSED RULE)

PHYSICIAN QUALITY REPORTING INITIATIVE (PQRI)

PQRI is a voluntary reporting program, first implemented in 2007, that provides an incentive payment to identified eligible professionals (EPs) who satisfactorily report data on quality measures for covered professional physician fee schedule (PFS) services furnished to Medicare Part B FFS beneficiaries during a specified reporting period.  In CMS’s calendar year 2011 proposed Physician Fee Schedule rule, CMS proposes to implement several provisions of the Affordable Care Act (ACA) that changed the structure and function of the PQRI program.

The PQRI incentive program generally operates on a calendar year basis.  As a result of ACA, PQRI incentive payments are authorized through calendar year 2014, with a penalty thereafter for EPs who do not satisfactorily report.  For 2011, ACA states that EPs may earn an incentive payment of 1.0 percent of the EP’s estimated total allowed charges for covered professional PFS services under Medicare Part B provided during the reporting period.  

CMS proposes a number of key changes in calendar year 2011 for PQRI, including:

·    Adding 20 individual PQRI measures (including new measures for reporting through registries and electronic health records) and one new measures group on which individual EPs may report;

·    Making 12 additional individual PQRI measures available for reporting through electronic health records systems (EHRs), in addition to the 10 measures already available for EHR reporting

·    Reducing the reporting sample requirements for claims- based reporting of individual measures from 80% to 50%, which could lessen the burden on EPs to qualify for incentive payments; and

Creating a new Group Practice Reporting Option (GPRO) that would allow group practices with fewer than 200 EPs to participate, which could broaden the ability of EPs to qualify at the group level (in addition to retaining the existing GPRO model for groups with 200 or more EPs).CMS also proposes and discusses changes to the structure and function of the PQRI program for 2011 and subsequent program years, in accordance with the PQRI changes included in ACA.  These changes include:

·    Extending PQRI incentive payments for years 2012 through 2014 by providing an incentive payment of 0.5 percent the EPs estimated total allowed charges for covered professional PFS services under Medicare part B provided during the applicable reporting period;

·    Implementing PQRI payment penalties beginning in 2015 for EPs (and group practices) that do not satisfactorily report data on quality measures by reducing the fee schedule payment by 1.5 percent in 2015 and 2.0 percent in 2016 and thereafter;

·    Providing timely feedback reports to EPs about satisfactory PQRI reporting, including proposals for interim feedback reports;

·    Creating an informal review process for EPs who wish to have CMS review its determination that an EP has not submitted data for PQRI satisfactorily;

·    Allowing EPs to qualify for an additional 0.5 percent incentive if they satisfactorily report PQRI measures and participate in a Maintenance of Certification program required for board certification by a recognized physician specialty organization for at least one year and complete a practice assessment as part of that organization’s Maintenance of Certification program;

·    Establishing  the framework for a new Physician Compare website; and

·    Describing CMS’ plans to integrate its reporting on quality measures under PQRI with the reporting elements required by the Electronic Health Record (her) Incentive Program (established under a separate regulation).

ELECTRONIC PRESCRIBING (eRx) INCENTIVEPROGRAM

Beginning in 2009, CMS implemented an E-Prescribing Incentive program for EPs who are “successful electronic prescribers” (e-prescribers), as defined by the Medicare Improvements for Patients & Providers Act (MIPPA) of 2008.  EPs and group practices who are successful e-prescribers for 2011 may earn an incentive payment of 1.0 percent of the EP’s (or group practice’s) estimated total allowed charges for PFS services under Medicare Part B  provided during the reporting period.  Beginning in 2012, the program will impose penalties on EPs who are not successful e-prescribers.  The reporting period for incentive payments under the eRx Incentive Program for 2011 will be the whole calendar year, and incentives will be paid based on the covered professional services furnished by an EP during the reporting year.

Key changes and proposals for Calendar Year 2011 under the proposed rule would:

·    Clarify that EPs who participate and qualify for the Medicare Electronic Health Records Incentive Program (to be established under separate regulations) for calendar year 2011 may not receive a separate, additional Medicare eRx Incentive Program payment;

·    Further clarify that EPs who receive incentives under the EHR Incentive Program for calendar year 2011 could still be subject to a penalty applicable in 2012 for not participating and being a successful electronic prescribers in the eRx Incentive Program in 2011;

·    Broaden opportunities for group practices with fewer than 200 members to participate in the eRx Incentive Program as  group practices; and

·    Establish criteria for applying the penalty applicable in 2012 or 2013 that EPs (and group practices) may incur if they do not participate successfully in the eRx Incentive Program in 2011 or 2012, including a proposed process for hardship exemptions.

CMS will accept comments on the proposed rule until August 24, and will respond to all comments in a final rule to be issued by November 1, 2010.  Unless otherwise specified, the new payment rates and policies will apply to services furnished to Medicare beneficiaries on or after January 1, 2011.

For more information, please see proposed rule for comments until August 24, 2010: 

http://www.regulations.gov/search/Regs/home.html#documentDetail?R=0900006480b182c9

For more information on the PQRI program visit: www.cms.gov/pqri.

For more information on the E-Prescribing Incentive program, visit:  www.cms.gov/erxincentive.