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Questions and Answers on the New Voluntary Medicare Reporting Program
The Tax Relief and Health Care Act of 2006 mandated that the Centers for Medicare and Medicaid Services (CMS) implement a new voluntary quality reporting program called the “Physician Quality Reporting Initiative (PQRI).” The PQRI began on July 1, 2007 and continues through 2008, although future legislation may extend the program.
As discussed further in this question and answer (Q & A) article, the APA Practice Directorate has serious concerns about the program, particularly as it is being implemented in its initial stages. We will continue our work to assure that psychologists and their patients are not disadvantaged by the PQRI.
Among our primary concerns, the program measures do not reflect psychologists’ professional services. The PQRI measures for 2007 are mandated by law to be taken solely from an earlier demonstration program for physicians. To be eligible for the PQRI in 2008, new measures must be developed using a consensus-based process involving multiple organizations and then must be approved or endorsed by a separate consensus organization. To date, most of the measures approved or endorsed by the leading consensus organizations involved in health care have been developed by and intended for use by physicians.
This Q and A provides information about the PQRI and offers practical guidance for psychologists who participate in Medicare and want to consider the possibility of participating in the PQRI for 2007.
Q. What is the Physician Quality Reporting Initiative (PQRI)?
A. PQRI is a new voluntary program that provides a financial incentive for certain health care professionals, including psychologists, to report on designated measures when filing claims for Medicare services. For 2007, the program involves services provided from July 1 through December 31 and involves 74 measures that describe a wide variety of health care services. Even though the program uses “physician” in the title, the legislation creating the PQRI stipulates that psychologists are among the Medicare providers who are eligible to participate.
Q. Is the PQRI a “pay-for-performance” program?
A. No. Pay for performance involves realigning incentives in health services delivery to reward quality improvement. The PQRI allows health care professionals to earn bonus payments just for reporting on the program’s measures, regardless of treatment outcomes. CMS has indicated that the current reporting program could serve as the foundation for a future Medicare pay-for-performance program.
Q. Do the measures reflect the services I provide to Medicare beneficiaries?
A. For the initial reporting period starting on July 1, the measures generally do not address the types of services that psychologists typically provide. The reason is that the legislation creating the PQRI required CMS to use an earlier demonstration version of the program that was limited to physicians. Of the 74 total measures for 2007, only one relates to mental health.
Additional measures are in the works for 2008. CMS will post a proposed set of measures in August for public comment and will release the final set of measures for 2008 this November. APA already has submitted comments on three of the measures – patient co-development of a treatment plan, screening for clinical depression, and screening for cognitive impairment – being considered for next year and has identified changes needed to make the measures more appropriate for use by psychologists.
Q. What’s the one measure for 2007 related to mental health?
A. The one measure for 2007 involves reporting on patients who are suffering from major depressive disorder (MDD) and have been prescribed, or at least evaluated for, the use of antidepressant medication during the acute phase of MDD.
Q. How can psychologists report on a measure that involves medication?
A. The measure is not limited to only the health care professional who prescribed the antidepressant medication. You can report on the measure if you are providing psychotherapy or a diagnostic interview to a patient who suffers from depression and is taking antidepressant medication prescribed by a physician, prescribing psychologist, nurse practitioner or other health care professional authorized to prescribe. You could also report the measure if the patient was evaluated for antidepressant medication by a prescribing health care professional even if the medication was subsequently not prescribed.
Q. How do I participate in the PQRI?
A. Medicare providers who want to participate in the PQRI do not need to apply separately for it. To participate, you simply will add a few codes to the electronic or paper claim form that you currently submit to Medicare. More detailed information, including instructions and a data collection sheet for the measure involving patients with major depressive disorder, is available on the CMS website at http://www.cms.hhs.gov/pqri under the category of Educational Resources. Additional information also is available from your Medicare carrier.
Q. What requirements do I have to meet?
A.You must be enrolled as a Medicare provider under the clinical psychologist designation and have a National Provider Identifier (NPI).
Q. What is the financial incentive for participating?
A.Health care professionals who report on 80 percent of the applicable cases for the one measure related to mental health will be eligible for a bonus payment of up to 1.5% of their total allowed Medicare charges for the reporting period. That’s 1.5% extra for all of the claims that Medicare pays you for, not just the ones you report on in connection with the PQRI.
Q. So I will receive an extra 1.5% whenever I’m paid for a Medicare claim?
A.It won’t happen right away. All 2007 claims have to be filed before CMS can calculate the bonus payments. Since the deadline for the 2007 claims is February 28, 2008, the agency will be issuing the bonus payments later in 2008.
Q. Do I have to start reporting immediately on July 1?
A. No, but you should not take too long to decide if you want to participate in the program for 2007. Because you must report on 80 percent of the applicable cases during the reporting period, failure to start early could prevent you from reaching this threshold and make you ineligible for the bonus payment.
Q. What if I have further questions about how to report under the PQRI?
A.The best place to seek additional information is your local Medicare carrier. CMS has been training the local carriers in preparation for the July 1 start date. You also may contact government relations staff for the APAPO by sending an Email or calling (+1/202) 336-5889.
Q. Why are there not more measures applicable to psychologists?
A. The APA Practice Directorate has advocated for additional measures. However, the strict limitations of the legislation creating the PQRI made it impossible for any of the health professional specialty societies to introduce new measures for 2007. APA and CMS are working so that psychologists will have additional measures to report on in 2008.
In addition to suggesting other measures, APA sought to modify the 2007 program measure on antidepressant medication to include treatment with only psychotherapy. Our request was rejected on the grounds that it would have significantly changed the measure, thereby violating the legislation that created the PQRI.
Q. What additional concerns does the APA Practice Directorate have about thePQRI?
A. We are dissatisfied with the PQRI in its present format, which does not provide psychologists with the opportunity to report on measures designed to appropriately reflect the delivery of psychological services. Before making any recommendations about using the one mental health measure for 2007, the Practice Directorate is pursuing further clarification from CMS. We want to understand the implications of reporting on a measure that only recognizes medication as a treatment for depression. We want to be certain that reporting on this measure as the program is constructed does not have the adverse consequences of creating over reliance on the use of medication in treating depression while precluding appropriate recognition of psychotherapy as an effective treatment for depression. We recognize, however, that the PQRI program is expected to grow and could have an even greater impact on Medicare reimbursement in future years. We also realize that a number of psychologists will be interested in the bonus payment offered for reporting. For these reasons, we will continue to provide input to CMS on any proposed measures and will advocate for psychology to be actively involved in the development of additional measures intended for use with psychological, behavioral or mental health services.
For additional information about our concerns with the PQRI, see Dr. Russ Newman’s Professional Point column, “Medicare reporting: what’s the payoff?” in the July-August 2007 issue of APA’s Monitor on Psychology..
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