By Ruth Carol, contributing writer, October 01, 2011
Whether or not the Patient Protection and Affordable Care Act survives ongoing challenges to its constitutionality, the notion of quality reporting forges ahead. As it does, quality reporting widens its purview to include community-based providers in addition to hospitals. Moreover, it moves from the realm of voluntary to mandatory as incentives give way to penalties.
Meanwhile, dermatologists are grappling with how quality reporting fits with other initiatives, such as electronic health records (EHRs) and e-prescribing, in order to move forward with all of them.
“Hospitals are used to this measurement environment,” said Alison Shippy, the American Academy of Dermatology’s senior manager of quality. For years, hospitals have been reporting various quality measures to their state health departments as well as the federal government. Among those measures are the Inpatient Quality Indicators and the Patient Safety Indicators from the Agency for Healthcare Research and Quality and the ever-growing list of measures in the Centers for Medicare and Medicaid Services (CMS) Hospital Inpatient Quality Reporting Program, as well as the the National Quality Forum’s (NQF’s) Serious Reportable Events (also known as never events). But as Shippy pointed out, patients receive most of their care from office-based providers and not at the hospital. Consequently, one- and two-physician practices are being encouraged, through the use of incentives and penalties, to do this type of reporting, she said.[pagebreak]
When the Physician Quality Reporting Initiative was getting underway, physicians were asked to voluntarily report data on quality measures for treating Medicare beneficiaries, with the potential for a bonus payment. Four years later, physicians are still being encouraged, through incentives, to participate in the Physician Quality Reporting System (PQRS). But in 2015, those who don’t participate will face penalties.
Quality reporting matters
The purpose of quality reporting is to try to ensure that physicians are providing a standard of care that meets best practices, which the majority of physicians are doing, said Oliver J. Wisco, DO, incoming chair of the Academy’s Performance Measurement Task Force. “If you report that you’re using best practices, you’re showing that you’re doing what’s right, and you’re a better physician than one who is not using them.”
Reporting will be particularly important in the near future as the upcoming pay-for-performance reimbursement systems will be partially based on how physicians perform, he added. More and more private and public payers are seeking out providers who offer the best care for their beneficiaries, Shippy said, adding, “Reporting quality measures is one way for dermatologists to demonstrate their value to those payers.”
Dermatologists also can use the knowledge of how well they stack up against best practices and evidence-based measures to drive improvement in their own practices, she said. For example, they may identify a practice gap, such as conducting a full-body screening or providing appropriate counseling, which once implemented may improve patient outcomes.
“The basic principle is anything that gets measured gets improved,” said James Ertle, MD, former chair of the AAD’s Quality Care Committee. “That’s why the government loves [quality initiatives], payers love them, and malpractice insurance companies love them.”
Quality reporting can also be important from the patients’ perspective. “Patients want to be able to make informed decisions about their health care and they want to know how physicians compare to each other,” Shippy said. Beginning in 2013, the CMS Physician Compare website will publicly report physician performance derived from PQRS data gathered in 2012. Currently, the site lists providers who participated in PQRS in 2009.
That year, 900 dermatologists (out of approximately 2,000 who reported in the specialty) earned an average PQRS incentive of more than $5,000, according to a recent report. That figure represents approximately 9 percent of all self-designated dermatology specialists eligible to participate.
That number is not surprising to Dr. Ertle, who said that any type of voluntary task typically results in a 10 percent response rate. “Incentives might work to raise that number a bit,” he said. “I suppose penalties will work more.”[pagebreak]
As the system becomes more efficient, Dr. Wisco expects more dermatologists to participate. “As with any new system, people are slow to change both because of apprehension of the change and because new systems always have several bugs that need to be worked out,” he said.
Hillary Johnson-Jahangir, MD, PhD, director of Mohs micrographic and dermatologic surgery at Weill Cornell Medical Center in New York City, believes that the time commitment, financial burden, and logistics associated with PQRS participation are keeping dermatologists from reporting quality measures. Participating in the PQRS is easy for Dr. Johnson-Jahangir because she does it through the EHR implemented by the academic center. “If there is a measure for which my patient qualifies, the EHR alerts me,” she said. “I don’t have time to think about it on my own.” (Some PQRS measures can be reported via claims, though the melanoma measures may only be reported via registry.)
On the down side, filling out the EHR takes a significant amount of time, which she doesn’t have during the day because, like most dermatologists, Dr. Johnson-Jahangir sees a high volume of patients. “Our specialty is very service-oriented. Patients don’t like you typing in notes instead of focusing on their conversation and skin exam,” added Dr. Johnson-Jahangir, who often spends several hours at night completing the EHRs.
Additionally, most of the quality measures are geared toward primary care physicians rather than specialists, she said. That means Dr. Johnson-Jahangir must address medical issues, such as elevated body mass index, which traditionally are unrelated to skin care, but have a bigger role in preventive medicine. Addressing such issues may mean informing the patient that his/her body mass index is elevated and the patient should discuss it further with his/her primary care physician.
Like many dermatologists, Dr. Ertle will be training staff to participate in PQRS as well as e-prescribing. He is in the process of acquiring an EHR that will make both tasks easier. The costs associated with quality reporting, e-prescribing, and an EHR system, and ensuring that they all work together, are a definite deterrent for dermatologists. “When you look at the cost of doing quality reporting versus the penalty of not doing it, many physicians will take the penalty,” he said. Dr. Ertle also believes that physicians look at quality reporting as just another mandate. “I don’t think anyone has adequately made the case for how these programs can improve the quality of care, so physicians don’t see the worth of it.” Currently, Dr. Ertle doesn’t see a lot of melanoma patients. Those he does see are younger and therefore are not Medicare beneficiaries.
Dr. Ertle is not alone in trying to juggle PQRS, EHRs, and e-prescribing with providing high quality care to his patients. Many dermatologists are waiting until they can acquire an EHR that is capable of being used with a quality reporting system, Shippy noted.
To that end, the Academy recently worked with two EHR vendors, NexTech and Encite, to add functionality to their products that automates the process of entering quality reporting data into the Academy’s Quality Reporting System. The added functionality will allow users to report quality measures without having to re-enter information into a registry. Dermatologists who would like their vendors to add this functionality, and vendors interested in working with the Academy to add it, can contact Shippy at email@example.com.[pagebreak]
For dermatologists participating in PQRS this year, there are three melanoma measures to report on. In 2012, a fourth measure related to biopsy follow-up will be added. The PQRS has been criticized for its lack of dermatology-specific measures.
The existing measures are rudimentary for dermatology, Dr. Johnson-Jahangir said. Hemoglobin A1c levels for diabetes patients, for example, can be measured, but it’s not as clear cut for skin diseases. Moreover, not all dermatologists see enough Medicare patients with melanoma to report on. “We don’t know if the information that we’re collecting will make a meaningful difference in the quality of our patients’ health,” she said, adding, “We need a greater variety of measures that are more intuitive for our specialty.”
The AAD is working to develop more robust measures for inclusion in the PQRS. Psoriasis is likely the next condition to be addressed following the publication of a six-part guideline in the Journal of the American Academy of Dermatology, Shippy said. It takes a significant amount of time to develop measures and to get them tested, endorsed by NQF, and incorporated into the PQRS, she noted. The last two steps alone can easily take two years to accomplish. An overview of the process to develop measures is offered at www.aad.org/education-and-quality-care/performance-measurement-and-quality-reporting/performance-measurement.
While dermatologists are not the largest group of specialists reporting into the PQRS, their numbers appear to be growing. In 2010, more than 840 dermatologists participated through the AAD registry. In 2011, more than 600 dermatologists are already signed up to participate, Shippy said. “I would expect as the penalties come closer, more dermatologists will participate,” she added.[pagebreak]
Dermatologists who are unsure about whether or not to participate in PQRS this year should review the reports on their Medicare melanoma patients, Shippy said. Determine how many patients have a history of melanoma and how many patients have new instances of melanoma. “Even if you decide to wait until next year, start planning ahead,” she advised. As an example, focus on implementing an EHR this year and start reporting in 2012. In order not to be penalized on Jan. 1, 2015, dermatologists must be participating in PQRS in 2013, said Shippy, explaining that CMS will be looking ahead of time to determine participation, similar to what it did with e-prescribing.
Dr. Wisco believes that the timing and logistics of PQRS participation will likely change during the next couple of years. “The process will be revised as it moves forward,” he said. “Dermatologists should get in the mindset now that they will have to start reporting measures. They should get organized so that they are ready when these changes occur.”
Current quality reporting for dermatologists
Medicare’s Physician Quality Reporting System (PQRS) allows physicians to be eligible for a bonus payment of 1 percent of their total Medicare Part B allowed charges if they report on at least three quality measures in 2011. Dermatologists can report on melanoma measures 137, 138, and 224. Full melanoma measure descriptions as well as a list of other PQRS measures that apply to dermatology are posted at www.aad.org/education-and-quality-care/performance-measurement-and-quality-reporting/medicare-physician-quality-reporting-system.
The melanoma measures can be reported only through a qualified electronic registry. If dermatologists choose to report on the three melanoma measures, they must report on at least 80 percent of their eligible patients for measures 137 and 224, and on at least 80 percent of their eligible visits for measure 138. Each of the quality measures must have at least one eligible instance for a dermatologist to qualify for the incentive. Since the only applicable diagnosis for measure 138 is a new diagnosis of melanoma, dermatologists must see at least one patient with a new diagnosis of melanoma (who is also a Medicare patient) in order to report measure 138 successfully. Additionally, you must successfully meet the measure for at least one patient per measure.
The Academy continues to provide practice support by offering an online reporting registry the Quality Reporting System (QRS) for members to report their PQRS data to CMS. Participants in 2011 could choose either a one-year reporting period, Jan. 1 Dec. 31, 2011, or a six-month reporting period, July 1 Dec. 31, 2011. The incentive will be based only on claims filed during the chosen reporting period. The final day to purchase the Academy’s registry ($249) will be Dec. 16, 2011 and the final day to enter and submit all data into the registry is Jan. 31, 2012. All associated claims must be processed by the end of February 2012. Visit www.aad.org/QRS to purchase the 2011 Physician Quality Reporting System Melanoma Reporting module.