Larger bonuses and penalties coming for Medicare

The National Psychologist March/April 2014, Vol 23, 2, pp 6-7.

Larger bonuses and penalties coming for Medicare

By Paula E. Hartman-Stein, Ph.D.

            Medicare’s current emphasis on pay-for-reporting will likely shift to pay-for-performance in which providers could earn bonuses or penalties of 4 percent in 2018 and up to 12 percent in 2021 and beyond.

            In order to abolish the sustainable growth rate (SGR) formula and avert a 23.7 percent rate reduction in Medicare reimbursement, bipartisan companion bills were introduced recently by the leadership of the House Ways and Means Committee, the House Energy and Commerce Committee and the Senate Finance Committee.

            James Georgoulakis, Ph.D., J.D., APA’s advisor to the American Medical Association’s Relative Update Committee, said the new program is called the Merit-Based Incentive Payment System (MIPS) with the versions submitted by the three committees differing somewhat on the rules, including the amounts of penalties and bonuses.

            According to a comparison chart on the AMA website that explains the bills, the Physician Quality Reporting System (PQRS) “best practice” measures will continue to be used in the MIPS as a means of improving quality of care.

            The proposals are drafted as “revenue neutral,” so where will the money come from to pay for performance bonuses? From the penalties for noncompliance, Georgoulakis said. “The money for the increase is going to come from those individuals who are not participating in the program. For example, psychologists who refuse to participate will pay for bonuses of psychiatrists who do.”

            He said regardless of disgruntlement among providers regarding PQRS, Congress is intent on reducing health care costs while improving patient care.

            And PQRS may not affect only Medicare providers for long. Most quality measures can be used for patients age 18 +, not only for geriatric patients. A few measures can be used for children age 12 and above. Georgoulakis predicts that other third party payers will adopt the penalties for clinicians who refuse to report quality measures once a decision is made on which congressional plan will be put into effect.

            When Medicare announced that practitioners failing to meet reporting requirements on quality of care in 2013 would incur automatic 1.5 percent reductions in payments in 2015, many psychologists bristled. The requirements were minimal then. To avoid penalties a practitioner needed report only one “best practices” measure on one patient.

            Many had ignored the “carrots” that began in 2008 for psychologists and social workers with a possible bonus of 1.5 percent that climbed to 2 percent payment in 2009 and 2010 for reporting three best practice measures, such as screens for pain, depression or elder maltreatment. CMS data revealed that only 3 percent of psychologists who are Medicare providers participated in PQRS in 2010. 

            Bonuses have declined while requirements have increased. From 2012 to 2014 bonuses decreased to 0.5 percent. In 2014 the number of measures required to report jumped from three to nine.

            There is an exception to the nine measure requirement. A system of reviewing medical claims called Measure Applicability Validation (MAV) will occur for Medicare providers who report less than nine measures to determine if they reported adequately to receive the bonus. The complex and extensive rules are found in hundreds of pages on the CMS.Gov website.

 

            In 2014 there are 287 measures physicians can choose to report while psychologists currently have about 12 available, depending upon the setting where they practice. For example, in primary care psychologists may be able to report body mass index screening and follow up, screen for high blood pressure or reconcile medications for patients recently discharged from an in-patient facility. Neuropsychologists may choose to report nine measures specific for patients with dementia if they sign up for a Registry.

            One reporting option open to physicians is the Group Practice Reporting Option (GPRO) via Web Interface that includes 22 individual measures that target high cost chronic conditions, preventive care and patient safety.

            Why does the American Medical Association support the PQRS program that many of its members find time consuming and cumbersome?

            “The AMA is concerned if they are not players in the system, the system will play without them,” Georgoulakis said. He said the AMA wants to get involved more in how the payments are structured.     .

            “Are psychologists thinking about these things?” he asked rhetorically. “The APA is supportive of PQRS, but the membership isn’t supporting it. While many are still waiting to roll back the clock, the train has left the station.”

            Georgoulakis contends that the driving force behind PQRS is not to stamp out fraud. However, he speculates that providers who are not reporting the measures may be opening themselves up to audits. As a health care attorney and psychologist, Georgoulakis gets calls from psychologists with audit problems. He said, “In the last 18 months, not one of the over 50 psychologists I have worked with has been participating in PQRS.  I am not assuming cause and effect.  I realize it is a small sample size, but at the very least it is odd that I don’t have at least one.

             Are there alternatives to playing by the PQRS rules? Georgoulakis said if patients pay cash, the clinician does not have to be concerned.

            Antonio Puente, Ph.D., neuropsychologist and voting member of the AMA’s panel of the Current Procedural Terminology (CRT) Committee, said “The PQRS is here to stay. As health care moves from fee for service to pay for performances, the initial step toward that decade long migration will be to focus on documentation. PQRS appears to be the most viable standardized and professionally vetted system for documentation.”

            However inevitable the changes appear to those close to federal decision makers, an informal email poll of about 70 rank-and-file practicing psychologists indicates opinions ranging from vehemently opposed to supportive.

            P. Scott Parker, Ph.D., of Indianapolis said, “Several other psychologists and I are writing our congressional reps and imploring them to stop PQRS, as we view it as yet another expansion of an ever-expanding bureaucracy and, in our opinion, a major impediment to the provision of our services to Medicare patients.” Parker added, “I have been practicing for the past 18 years and will absolutely not comply with PQRS.”

            Bruce H. Vermeer, Psy.D., of Wyoming, Mich., said, “I believe PQRS is an extremely poor approach to assuring quality care. The quest for excellent quality care begins in the graduate school classroom, when such concepts are being developed by students. Our government has absolutely no business legislating such matters. That is not a productive use of time and resources!”

            Dori Bischmann, Ph.D., of Waukesha, Wisc., representative for APA at the Physician Consortium of Performance Improvement (PCPI), said, “PQRS has not improved the quality of my practice.” She is concerned about an apparent push toward reporting measures through large data base companies called registries. “Registries cost money to join. This makes it difficult for psychologists to participate,” she said. According to Bischmann, psychologists may be unduly penalized because the infrastructure in place favors physician practices, especially in large health care delivery systems.

            Peter Kanaris, Ph.D., APA’s public education coordinator, expressed mixed feelings. “Using the measures allows for the gathering of useful data and for some flexibility for the clinician to select relevant measures to his/her patient population, and it encourages the use of metrics to support clinical judgment. It encourages thoroughness in patient evaluation and helps to prevent clinician complacency.”

            But, said Kanaris, a negative aspect is the disruption in the flow of the session that can break the rapport with the patient. “It is a distraction from attending and focusing on patients in session. More subtle conversational approaches are replaced by screens that can confuse and intimidate an elderly population. It can be a pain in the neck.”

            Mary Schaffer, Ph.D., of Grand River, Ohio, said, “I am and  remain excited about the PQRS program as I am a strong advocate of utilizing clinical outcomes as a means of collecting pertinent data , formulating treatment plans, as well as, a monitoring tool for treatment outcomes. The most useful and rewarding measure for me has been screening and cessation intervention for tobacco use. However, the PQRS program has been mentally exhausting and time consuming at times. This is the first year I will not attempt to obtain an incentive payment as the request for nine measures is over the top and unreasonable in my opinion.”

            Stephen Daniel, Ph.D., of Johnson City, N.Y., said he found screening techniques for depression to be a beneficial area in nursing homes because it brings up conversations with nurses and physicians on the importance of anti-depressant medication and psychotherapy.

            “I am excited about these developments.” Donna Rasin-Waters, Ph.D., of New York, N.Y., said. “As psychologists and neuropsychologists we need to be participating in PQRS. This is the beginning of standardization of best practices and we should be honored to be included in these efforts.”

            According to Rasin-Waters, “Those not wanting to make these changes will find themselves far behind their colleagues once the reporting becomes fully transparent and consumers adapt to the system. It will be no different for psychologists. Would I choose to send a depressed loved one to the clinician who refuses to quantify the level of depression or screen for suicidal risk? I think not.”

 

            Paula Hartman-Stein, Ph.D., offers webinars and workshops to make PQRS simple for psychologists. She was former chair of the first psychology work group to develop measures for PQRS in 2007 and recently has been appointed to three technical expert panels to review measures for 2015. She can be reached through www.centerforhealthyaging.com.

 

 

The
National
Psychologist
March/April
2014,
Vol
23,
2,
p
6.
Larger
bonuses
and
penalties
coming
for
Medicare
By
Paula
E.
Hartman-­‐Stein,
Ph.D.
Medicare’s
current
emphasis
on
pay-­‐for-­‐reporting
will
likely
shift
to
pay-­‐for-­‐
performance
in
which
providers
could
earn
bonuses
or
penalties
of
4
percent
in
2018
and
up
to
12
percent
in
2021
and
beyond.
In
order
to
abolish
the
sustainable
growth
rate
(SGR)
formula
and
avert
a
23.7
percent
rate
reduction
in
Medicare
reimbursement,
bipartisan
companion
bills
were
introduced
recently
by
the
leadership
of
the
House
Ways
and
Means
Committee,
the
House
Energy
and
Commerce
Committee
and
the
Senate
Finance
Committee.
James
Georgoulakis,
Ph.D.,
J.D.,
APA’s
advisor
to
the
American
Medical
Association’s
Relative
Update
Committee,
said
the
new
program
is
called
the
Merit-­‐Based
Incentive
Payment
System
(MIPS)
with
the
versions
submitted
by
the
three
committees
differing
somewhat
on
the
rules,
including
the
amounts
of
penalties
and
bonuses.
According
to
a
comparison
chart
on
the
AMA
website
that
explains
the
bills,
the
Physician
Quality
Reporting
System
(PQRS)
“best
practice”
measures
will
continue
to
be
used
in
the
MIPS
as
a
means
of
improving
quality
of
care.
The
proposals
are
drafted
as
“revenue
neutral,”
so
where
will
the
money
come
from
to
pay
for
performance
bonuses?
From
the
penalties
for
noncompliance,
Georgoulakis
said.
“The
money
for
the
increase
is
going
to
come
from
those
individuals
who
are
not
participating
in
the
program.
For
example,
psychologists
who
refuse
to
participate
will
pay
for
bonuses
of
psychiatrists
who
do.”
He
said
regardless
of
disgruntlement
among
providers
regarding
PQRS,
Congress
is
intent
on
reducing
health
care
costs
while
improving
patient
care.
And
PQRS
may
not
affect
only
Medicare
providers
for
long.
Most
quality
measures
can
be
used
for
patients
age
18
+,
not
only
for
geriatric
patients.
A
few
measures
can
be
used
for
children
age
12
and
above.
Georgoulakis
predicts
that
other
third
party
payers
will
adopt
the
penalties
for
clinicians
who
refuse
to
report
quality
measures
once
a
decision
is
made
on
which
congressional
plan
will
be
put
into
effect.
When
Medicare
announced
that
practitioners
failing
to
meet
reporting
requirements
on
quality
of
care
in
2013
would
incur
automatic
1.5
percent
reductions
in
payments
in
2015,
many
psychologists
bristled.
The
requirements
were
minimal
then.
To
avoid
penalties
a
practitioner
needed
report
only
one
“best
practices”
measure
on
one
patient.
Many
had
ignored
the
“carrots”
that
began
in
2008
for
psychologists
and
social
workers
with
a
possible
bonus
of
1.5
percent
that
climbed
to
2
percent
payment
in
2009
and
2010
for
reporting
three
best
practice
measures,
such
as
screens
for
pain,
depression
or
elder
maltreatment.
CMS
data
revealed
that
only
3
percent
of
psychologists
who
are
Medicare
providers
participated
in
PQRS
in
2010.
Bonuses
have
declined
while
requirements
have
increased.
From
2012
to
2014
bonuses
decreased
to
0.5
percent.
In
2014
the
number
of
measures
required
to
report
jumped
from
three
to
nine.
There
is
an
exception
to
the
nine
measure
requirement.
A
system
of
reviewing
medical
claims
called
Measure
Applicability
Validation
(MAV)
will
occur
for
Medicare
providers
who
report
less
than
nine
measures
to
determine
if
they
reported
adequately
to
receive
the
bonus.
The
complex
and
extensive
rules
are
found
in
hundreds
of
pages
on
the
CMS.Gov
website.
In
2014
there
are
287
measures
physicians
can
choose
to
report
while
psychologists
currently
have
about
12
available,
depending
upon
the
setting
where
they
practice.
For
example,
in
primary
care
psychologists
may
be
able
to
report
body
mass
index
screening
and
follow
up,
screen
for
high
blood
pressure
or
reconcile
medications
for
patients
recently
discharged
from
an
in-­‐patient
facility.
Neuropsychologists
may
choose
to
report
nine
measures
specific
for
patients
with
dementia
if
they
sign
up
for
a
Registry.
One
reporting
option
open
to
physicians
is
the
Group
Practice
Reporting
Option
(GPRO)
via
Web
Interface
that
includes
22
individual
measures
that
target
high
cost
chronic
conditions,
preventive
care
and
patient
safety.
Why
does
the
American
Medical
Association
support
the
PQRS
program
that
many
of
its
members
find
time
consuming
and
cumbersome?
“The
AMA
is
concerned
if
they
are
not
players
in
the
system,
the
system
will
play
without
them,”
Georgoulakis
said.
He
said
the
AMA
wants
to
get
involved
more
in
how
the
payments
are
structured.
.
“Are
psychologists
thinking
about
these
things?”
he
asked
rhetorically.
“The
APA
is
supportive
of
PQRS,
but
the
membership
isn’t
supporting
it.
While
many
are
still
waiting
to
roll
back
the
clock,
the
train
has
left
the
station.”
Georgoulakis
contends
that
the
driving
force
behind
PQRS
is
not
to
stamp
out
fraud.
However,
he
speculates
that
providers
who
are
not
reporting
the
measures
may
be
opening
themselves
up
to
audits.
As
a
health
care
attorney
and
psychologist,
Georgoulakis
gets
calls
from
psychologists
with
audit
problems.
He
said,
“In
the
last
18
months,
not
one
of
the
over
50
psychologists
I
have
worked
with
has
been
participating
in
PQRS.
I
am
not
assuming
cause
and
effect.
I
realize
it
is
a
small
sample
size,
but
at
the
very
least
it
is
odd
that
I
don’t
have
at
least
one.
Are
there
alternatives
to
playing
by
the
PQRS
rules?
Georgoulakis
said
if
patients
pay
cash,
the
clinician
does
not
have
to
be
concerned.
Antonio
Puente,
Ph.D.,
neuropsychologist
and
voting
member
of
the
AMA’s
panel
of
the
Current
Procedural
Terminology
(CRT)
Committee,
said
“The
PQRS
is
here
to
stay.
As
health
care
moves
from
fee
for
service
to
pay
for
performances,
the
initial
step
toward
that
decade
long
migration
will
be
to
focus
on
documentation.
PQRS
appears
to
be
the
most
viable
standardized
and
professionally
vetted
system
for
documentation.”
However
inevitable
the
changes
appear
to
those
close
to
federal
decision
makers,
an
informal
email
poll
of
about
70
rank-­‐and-­‐file
practicing
psychologists
indicates
opinions
ranging
from
vehemently
opposed
to
supportive.
P.
Scott
Parker,
Ph.D.,
of
Indianapolis
said,
“Several
other
psychologists
and
I
are
writing
our
congressional
reps
and
imploring
them
to
stop
PQRS,
as
we
view
it
as
yet
another
expansion
of
an
ever-­‐expanding
bureaucracy
and,
in
our
opinion,
a
major
impediment
to
the
provision
of
our
services
to
Medicare
patients.”
Parker
added,
“I
have
been
practicing
for
the
past
18
years
and
will
absolutely
not
comply
with
PQRS.”
Bruce
H.
Vermeer,
Psy.D.,
of
Wyoming,
Mich.,
said,
“I
believe
PQRS
is
an
extremely
poor
approach
to
assuring
quality
care.
The
quest
for
excellent
quality
care
begins
in
the
graduate
school
classroom,
when
such
concepts
are
being
developed
by
students.
Our
government
has
absolutely
no
business
legislating
such
matters.
That
is
not
a
productive
use
of
time
and
resources!”
Dori
Bischmann,
Ph.D.,
of
Waukesha,
Wisc.,
representative
for
APA
at
the
Physician
Consortium
of
Performance
Improvement
(PCPI),
said,
“PQRS
has
not
improved
the
quality
of
my
practice.”
She
is
concerned
about
an
apparent
push
toward
reporting
measures
through
large
data
base
companies
called
registries.
“Registries
cost
money
to
join.
This
makes
it
difficult
for
psychologists
to
participate,”
she
said.
According
to
Bischmann,
psychologists
may
be
unduly
penalized
because
the
infrastructure
in
place
favors
physician
practices,
especially
in
large
health
care
delivery
systems.
Peter
Kanaris,
Ph.D.,
APA’s
public
education
coordinator,
expressed
mixed
feelings.
“Using
the
measures
allows
for
the
gathering
of
useful
data
and
for
some
flexibility
for
the
clinician
to
select
relevant
measures
to
his/her
patient
population,
and
it
encourages
the
use
of
metrics
to
support
clinical
judgment.
It
encourages
thoroughness
in
patient
evaluation
and
helps
to
prevent
clinician
complacency.”
But,
said
Kanaris,
a
negative
aspect
is
the
disruption
in
the
flow
of
the
session
that
can
break
the
rapport
with
the
patient.
“It
is
a
distraction
from
attending
and
focusing
on
patients
in
session.
More
subtle
conversational
approaches
are
replaced
by
screens
that
can
confuse
and
intimidate
an
elderly
population.
It
can
be
a
pain
in
the
neck.”
Mary
Schaffer,
Ph.D.,
of
Grand
River,
Ohio,
said,
“I
am
and
remain
excited
about
the
PQRS
program
as
I
am
a
strong
advocate
of
utilizing
clinical
outcomes
as
a
means
of
collecting
pertinent
data
,
formulating
treatment
plans,
as
well
as,
a
monitoring
tool
for
treatment
outcomes.
The
most
useful
and
rewarding
measure
for
me
has
been
screening
and
cessation
intervention
for
tobacco
use.
However,
the
PQRS
program
has
been
mentally
exhausting
and
time
consuming
at
times.
This
is
the
first
year
I
will
not
attempt
to
obtain
an
incentive
payment
as
the
request
for
nine
measures
is
over
the
top
and
unreasonable
in
my
opinion.”
Stephen
Daniel,
Ph.D.,
of
Johnson
City,
N.Y.,
said
he
found
screening
techniques
for
depression
to
be
a
beneficial
area
in
nursing
homes
because
it
brings
up
conversations
with
nurses
and
physicians
on
the
importance
of
anti-­‐depressant
medication
and
psychotherapy.
“I
am
excited
about
these
developments.”
Donna
Rasin-­‐Waters,
Ph.D.,
of
New
York,
N.Y.,
said.
“As
psychologists
and
neuropsychologists
we
need
to
be
participating
in
PQRS.
This
is
the
beginning
of
standardization
of
best
practices
and
we
should
be
honored
to
be
included
in
these
efforts.”
According
to
Rasin-­‐Waters,
“Those
not
wanting
to
make
these
changes
will
find
themselves
far
behind
their
colleagues
once
the
reporting
becomes
fully
transparent
and
consumers
adapt
to
the
system.
It
will
be
no
different
for
psychologists.
Would
I
choose
to
send
a
depressed
loved
one
to
the
clinician
who
refuses
to
quantify
the
level
of
depression
or
screen
for
suicidal
risk?
I
think
not.”
Paula
Hartman-­‐Stein,
Ph.D.,
offers
webinars
and
workshops
to
make
PQRS
simple
for
psychologists.
She
was
former
chair
of
the
first
psychology
work
group
to
develop
measures
for
PQRS
in
2007
and
recently
has
been
appointed
to
three
technical
expert
panels
to
review
measures
for
2015.
She
can
be
reached
through
www.centerforhealthyaging.com.
Hartman-­‐Stein,
P.
(2014).
Larger
bonuses
and
penalties
coming
for
Medicare,
The
National
Psychologist
23,
p
6.