Fact Sheets

PHYSICIAN QUALITY REPORTING SYSTEM AND E-PRESCRIBING PROGRAM

PHYSICIAN QUALITY REPORTING SYSTEM

The Physician Quality Reporting System (formerly, the Physician Quality Reporting Initiative or PQRI) is a voluntary reporting program, first implemented in 2007, that provides an incentive payment to identified eligible professionals who satisfactorily report data on quality measures for covered professional Medicare Physician Fee Schedule (MPFS) services furnished to Medicare Part B fee-for-service (FFS) beneficiaries during a specified reporting period.  In CMS’s calendar year (CY) 2011 Physician Fee Schedule final rule with comment period, CMS implements several provisions of the Affordable Care Act that changed the structure and function of the Physician Quality Reporting System.

The Physician Quality Reporting System generally operates on a calendar year basis.  As a result of the Affordable Care Act, Physician Quality Reporting System incentive payments are authorized through CY 2014, with a payment adjustment thereafter for eligible professionals who do not satisfactorily report data on quality measures.  For 2011, eligible professionals may earn an incentive payment of 1.0 percent of the eligible professional’s estimated total Medicare Part B allowed charges for covered professional MPFS services furnished during the reporting period. 

CMS is making a number of key changes in CY 2011 for the Physician Quality Reporting System, including: 

• Adding 20 individual Physician Quality Reporting System measures (including new measures for reporting through registries and electronic health records) and one new measures group on which individual eligible professionals may report;

• Making 10 additional individual Physician Quality Reporting System measures available for reporting through electronic health records systems, in addition to the 10 measures already available for electronic health record reporting;

• Reducing the reporting sample requirements for claims-based reporting of individual measures from 80% to 50%, which lessens the burden on eligible professionals to qualify for incentive payments; and

• Creating a new Group Practice Reporting Option (GPRO) that allows group practices with fewer than 200 eligible professionals to participate, which broadens the ability of eligible professionals to qualify at the group level (in addition to retaining the existing GPRO model for groups with 200 or more eligible professionals).

In the Physician Fee Schedule final rule, CMS also described the following changes to the Physician Quality Reporting System in 2011 and subsequent program years as a result of the Affordable Care Act.  These changes include:

·       Physician Quality Reporting System incentive payments of 0.5 percent are authorized for years 2012 through 2014;

·       Physician Quality Reporting System payment adjustments are required beginning in 2015 for eligible professionals (and group practices) that do not satisfactorily report data on quality measures, and such payment adjustments would be made by reducing the fee schedule payment by 1.5 percent in 2015 and 2.0 percent in 2016 and thereafter;

·       CMS will provide timely feedback reports to eligible professionals about satisfactory reporting, including plans for interim feedback reports for claims-based reporting in future years;

·       CMS has created an informal review process for eligible professionals who wish to have CMS review its determination that an eligible professional has not satisfactorily submitted data for Physician Quality Reporting System in the 2011 program year;

·       Eligible professionals may qualify for an additional 0.5 percent incentive beginning in 2011 if they satisfactorily report data on the Physician Quality Reporting System quality measures through a Maintenance of Certification Program.  To receive the incentive payment, the eligible professional must participate in an organization’s Maintenance of Certification Program and complete a practice assessment as part of that program more frequently than is required to qualify for or maintain board certification status;

·       CMS is establishing the framework for a new Physician Compare website; and

·       CMS describes its work toward developing a plan to integrate its reporting on quality measures under the Physician Quality Reporting System with the reporting elements required by the Medicare Electronic Health Record (EHR) Incentive Program (established under a separate regulation).

ELECTRONIC PRESCRIBING (eRx) INCENTIVEPROGRAM

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

Key aspects of the eRx Incentive Program addressed in the CY 2011 final rule with comment period include:

• Broadening opportunities for group practices with fewer than 200 members to participate in the eRx Incentive Program as group practices;

• Establishing "successful -prescriber" criteria for determining application of the 2012 eRx payment adjustment, including a process for hardship exemptions;

• Clarifying that eligible professionals who receive incentives under the Medicare EHR Incentive Program for CY 2011 must still participate and meet the eRx payment adjustment requirements for successful e-prescribers under the eRx Incentive Program during the applicable reporting period 2011 to avoid the payment adjustment applicable in 2012; and 

• Further clarifying that eligible professionals who receive incentives under the Medicare EHR Incentive Program for CY 2011 may not receive a separate, additional incentive payment under the eRx Incentive Program.

The final rule with comment period will appear in the Nov. 29, 2010 Federal Register.  Unless otherwise specified, the new payment rates and policies will apply to services furnished to Medicare beneficiaries on or after Jan. 1, 2011.

For more information, please see:  www.federalregister.gov/inspection.aspx#special

For more information on the Physician Quality Reporting System program visit: https://qpp.cms.gov/

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

For more information on the Medicare and Medicaid EHR Incentive Programs, visit:   www.cms.gov/EHRIncentivePrograms.