PQRS: Why Radiologists Should Care

January 15, 2013

Most radiologists aren’t meeting CMS’ Physician Quality Reporting System requirements. But bonuses will soon turn to penalties. Overcome your objections with this guide.

The government wants to give you money - but you're probably leaving it on the table. And you're not alone.

Less than a quarter of radiologists qualified for the bonus money CMS hands out for meeting Medicare's Physician Quality Reporting System (PQRS) requirements. That's according to a study from the Harvey L. Neiman Health Policy Institute published in the Journal of the American College of Radiology. Researchers found that only 23.7 percent of eligible radiologists qualified for PQRS incentives in 2010, the most recent year for which data is available.

Why? Three big reasons are cost, confusion or outright contempt. Some physicians crunched the numbers and figured out the 0.5 percent bonus on Medicare billings didn't cover the cost of complying with PQRS.

Others tried to comply, but got contradictory instructions. And some threw up their hands and decided the whole process was meaningless - which is a shame, because the intentions behind PQRS are pure.

"Ostensibly, this was established as a first step in moving our payment system from one that's a fee-for-volume system to one that's a fee-for-value system," said Richard Duszak, MD, chief executive officer and senior research fellow of the Harvey L. Neiman Health Policy Institute.

Unfortunately, PQRS became "a multi-paradoxical type of system that winds up emphasizing a lot of regulatory processes over what was the core intent, which is quality," Duszak said. But he doesn't advocate ignoring PQRS. Instead, he urges radiologists to participate: "I think we all have to look at this as a step in the right direction rather than be cynical about the process."

How? Here’s our guide to overcoming common PQRS objections.

Objection No. 1: The bonus isn't big enough to bother.

A bonus payment of 0.5 percent doesn't sound like much - but it won't stay a bonus for long. In 2015, CMS will move to assessing penalties on physicians who don't participate in PQSR, and those penalties could rise to 2 percent or higher on all Medicare billings. What’s more, those penalties will be based on what happens this year, meaning what you don’t do now will come back to bite you in two years.

“It’s still early in 2013,” said Duszak. “There’s still 11 and a half months for folks who aren’t in the process to potentially achieve their metrics this year. Your performance in 2013 will dictate penalties for 2015.”

What's more, your compliance with the system will be a matter of record - a record your patients can see online on Medicare's Physician Compare website. "To some patients who aren't sophisticated enough to understand that this is a reporting metric and not a true quality metric, there may be some implications back to that practice," Duzsak said. "They may say 'Oh, Dr. Jones or Dr. Smith didn't meet his quality metric, he must not be a good doctor.'" You know that's not how the program works, but do you think you'll be able to explain that to potential patients?

Objection No. 2: It costs too much to comply.

Some billing companies are incorporating PQRS reporting into their services at no extra cost. But if you do your billing in-house, the costs may outweigh the bonus. If that's the case, Duzsak said, you might want to consider using a registry service instead.

"The registry gets composite data and reports them as a group," he said. "The key ones have been approved by CMS for reporting, so that information is accepted by CMS as a valid indicator that that physician had fulfilled his or her reporting responsibilities over the course of the year."

And besides, Medicare may not be the only entity paying for participation in the future, Larson said. "Other [payers] are going to start doing this, and you're going to set up a system that's going to get more money from more places in the future."

Objection No. 3: It takes too much effort.

Physicians actually have it easy, Larson said. "With a lot of people using voice recognition and templates for the reports these days, it's pretty easy to put in a line that says, for example, fluoroscopy time, which then reminds you to fill that in," Larson said. "More of this falls on whoever does your billing, whether you do that within your own practice or whether you use an outside billing firm. They're the ones that really are turning that information into a code that the CMS is looking at and using to track whether you're participating and whether you're submitting codes on enough of the patients."

Objection No. 4: The whole system is confusing and contradictory.

Well, yeah, this is government we're talking about. But things have improved since the start of the program, when practices and providers were getting contradictory advice on what we required.

That doesn't mean it's all smooth sailing, however. "You can get tripped up a little bit if Medicare decides some patients were eligible to be reported and you didn't report them. That's a way that people potentially fail," Larson said. "But as far as we can tell, there's no penalty if you submit the code on a patient and they say it's irrelevant. They don't say, 'And by the way, we're going to pay you less because you submitted a bad code.' You should probably err on the side of submitting anyone you think it might be relevant for."

Objection No. 5: The system doesn't measure actual quality, so why bother?

This is a tough one, because there's some truth to that. You get your bonus for reporting, not for reporting good things. "I think some people miss the point that reporting you didn't do the thing counts just as well as reporting that you did do the thing," Larson said. So, if you report that you didn't record your fluoroscopy time 75 percent of the time, that still counts, and you still get paid.

And that particular measurement can be maddening, Duzsak admits. The metric PQRS is looking for is did you report the fluoroscopy time, not whether that fluoroscopy time was appropriate. "To bring that to its illogical extreme, I could report I used six hours of fluoroscopy to perform a barium enema, a dose that no one would consider remotely appropriate, but still the coders would be able to apply it. And I would potentially get a bonus based on that," Duzsak said.

Metrics like that may be the crux of the PQRS image problem. "Folks feel like they're dotting these artificial i's and crossing these artificial t's, which really don't have substantial consequences for patient care," Duzsak said.

But Larson has an answer for these objections: "Get over it. Someone's offering you money for this. Just do it."