Published 5/1/2007
William Rogers, MD, FCEP

PQRI: A way to get more out of Medicare

Orthopaedists need only report on 3 measures to qualify

I dare say that every physician in the United States is aware that the Medicare program pays doctors less in 2007 than it did in 2001. Physician expenses have been increasing annually—office rent, staff salaries, and malpractice insurance premiums increase every year. What in the world are the bureaucrats who run Medicare thinking?

Attempts to limit spending
When the Medicare program was established in 1965, spending on physician services was modest, and local fee schedules were the rule. But Medicare spending grew dramatically over the next decades (
see Figure 1). In 1975 Congress intervened, limiting physician fee schedule increases to the rate of growth of the Medicare Economic Index. Spending continued to increase, and by 1984, Congress actually froze physician fee increases.

In 1987, 1992, and 1997, Congress imposed mathematical formulas intended to rein in physician spending. The last of those formulas, called the sustainable growth rate (SGR), has determined the physician fee schedule since 1997. The SGR formula prevents spending on physician services from growing much faster than real per capita gross domestic product. Because of rapid growth in spending on chemotherapeutic drugs and on imaging studies, as well as a more modest but very real growth in volume of other physician office services, the amount of money in the Medicare Part B pie available to pay physicians for an office visit has shrunk considerably.

The SGR formula has dictated a reduction in the physician fee schedule every year since 2001. Congress has intervened every year except 2002 to prevent the negative update, but the formula remains on the law books. Now, the Centers for Medicare and Medicaid Services (CMS) has predicted that physician payments will have to be reduced by 9.9 percent in 2008.

Congress is exploring alternatives to the SGR, but the budgetary implications are sobering. Freezing physician fees for the next 10 years would increase Medicare spending by $171 billion. Allowing physician spending to increase at the rate of the Medicare Economic Index for the next 10 years would cause Medicare spending to increase by $252 billion.

What’s a doctor to do?
This year, physicians do have an opportunity to pry a few more dollars out of the Medicare program. Under the Physician Quality Reporting Initiative (PQRI), Congress has allocated money to be awarded to participating physicians who report on quality measures to CMS.

Physicians—including orthopaedic surgeons—should consider participating in the PQRI. Measures reporting begins on July 1, 2007, using the Medicare claim form that the office generates already. Physicians who participate will get a check from Medicare, as well as a confidential report, which will give the reporting physicians a sense of their personal performance.

Unlike the hospital quality measures, physician measures will not be disseminated to the public. There are currently 74 measures, but orthopaedists will only need to report on three measures to qualify for the payment.

Detailed specifications of the measures are now available on the PQRI Web site. It should be a simple matter for a practice to develop a worksheet listing just the measures that the practice has elected to report.

If, for example, an orthopaedic practice decides to report on venous thromboembolism prophylaxis, the worksheet would list the CPT II code for that measure, and the doctor providing the care would check the box. When the billing |staff processes the chart, they need merely add the appropriate CPT II code to the claim form on line 24.

Further information on the PQRI is available online at www.cms.hhs.gov/pqri AAOS members who have questions about the program are encouraged to call in on the next physician open door forum. The date of the forum can be found at http://www.cms.hhs.gov/23

William Rogers, MD, FCEP, is director of the CMS Physicians Regulatory Issues Team (PRIT). For more information on the PRIT, visit www.cms.hhs.gov/prit