The initials “PQRI” float around in emergency department management articles, ACEP News, Scientific Assembly, and many other venues. Most physicians know the letters are related to Centers for Medicare and Medicaid Services reimbursement, and some know there are quality measurements to meet. But what exactly do the initials stand for? And why should you as a practicing physician care?

By staying ahead of the game, emergency physicians can capture extra revenue and avoid future reductions in pay.

What is PQRI?

PQRI stands for the Physician Quality Reporting Initiative. Congress started this program through a provision of the Tax Relief and Health Care Act of 2006. Since being implemented in mid-2007, the program pays physicians a small bonus for reporting on quality measures related to their specialty. The program currently is voluntary.

Why is it important (other than some extra cash in my pocket)?

There is extra payment for participation, although the amount can be small and is based on how many Medicare patients emergency physicians see. The bonus is up to 2% of your total Medicare-allowed charges for all Medicare patients. Billing companies estimate the bonus to be around $1,500 per emergency physician annually.

The importance of the program lies in a fundamental shift in CMS’s perspective on how the agency pays for services. Instead of rewarding volumes of services with payment, PQRI is a small step toward financial rewards for efficient and high-quality care. It is anticipated that in the future the bonus will turn into a requirement for full Medicare payment, the same way physicians caring for have been affected by the Core Measures and Present on Admission initiatives.

An additional important aspect of the PQRI program is the manner in which CMS sought physician input. Unlike other initiatives (such as the hospital Core Measures), CMS turned to physicians and asked for their input, guidance, and buy in. The majority of the PQRI measures were developed by the American Medical Association’s Physician Consortium for Performance Improvement (PCPI). ACEP is a standing PCPI member and actively participates. There are also vetting groups, such as the National Quality Forum, with which ACEP participates as well.

The change in approach was directed by federal statute, but was a change welcomed by physicians and ultimately their patients. (Everyone ready to stop measuring beta blockers in 24 hours and antibiotics for pneumonia within 4 hours?)

Of note, hospitals that fail to meet the reporting requirements for the hospital outpatient quality data reporting program are subject to a reduction of 2% from the market basket update to the conversion factor. It is in emergency physicians’ best interest to help their hospitals meet the program requirements. Eventually, there will be monetary penalties for physicians who don’t report quality measures.

What are the measures?

For 2009, emergency medicine has 11 measures to choose from, and the physician chooses 3 on which to report. A complete list of the measures and their descriptions is available at www.acep.org.

What do I need to know or do as a practicing physician?

First, especially for emergency physicians in an independent group, be sure the group’s billing company is capturing and successfully submitting these data. The group will need to select at least three measures it wants to report.

Then, be sure the documentation system being used helps easily document these measures. Get feedback from your coders to find out if they are having problems finding the correct documentation, including the reason the measure was not met (e.g., for aspirin within 24 hours for acute MI, aspirin was not given secondary to allergy to aspirin).

Finally, discuss how to distribute the annual bonus. One issue for groups has been that they cannot identify the payment by individual physician because it is a single payment to the group. Some groups add the extra money into a bonus pool based on productivity. Some billing companies can also provide reporting on individual physician compliance with the measures to help with distributions.

Are there any other CMS incentives for physicians?

Yes, E-prescribing. This incentive program, started for 2009, is not tied to PQRI, but has many similarities. A very important difference relates to the eventual decrease in Medicare reimbursement. The incentive bonus for 2009-2010 is 2%, for 2011-2012 is 1%, for 2013 is 0.5%, and then it starts to become a reduction in pay. Reductions will be 1% for 2012, 1.5% for 2013, and 2% for 2014 and on.

Emergency medicine received a waiver this year, because emergency physicians depend on the hospital to provide software and cannot independently control this aspect. However, in upcoming years, this may change.

Engage your hospital administrators to purchase electronic discharge programs that meet CMS’s criteria, which include an active medication list, alert systems for allergies and interactions, cost savings information, printed prescriptions, and electronic transmissions to pharmacies.

More information on the program can be found at www.cms.hhs.gov/ERxIncentive.

PQRI is here to stay and could evolve into a required program by CMS that will affect physician pay.

ACEP has an excellent PQRI FAQ on its Web site with detailed explanations about PQRI and the nuts and bolts of how to submit the data. See www.acep.org/practres.aspx?id=30492 for details. CMS also has information on the program at www.cms.hhs.gov/pqri.

By staying ahead of the game, emergency physicians and their groups can capture extra revenue and avoid future reductions in pay.