'Fiscal Cliff' Law To Affect Medicare's Quality Reporting

A provision of the so-called "fiscal cliff" legislation would encourage healthcare providers to use electronic registries to do quality reporting, notes Peter Orszag, former director of the Office of Management and Budget, in a recent Bloomberg article. Orszag interprets this provision as promoting registries to improve the quality of care, partly by comparing the outcomes of different treatments. However, the evidence points to a more targeted agenda, at least in the short term.

The American Taxpayer Relief Act of 2012, according to the Congressional Research Service, "authorizes eligible professionals to receive incentive payments under Medicare for reporting on quality measures by participating in a qualified clinical data registry." This sounds like it's related to the government's electronic health record incentive program, which requires EPs to attest to clinical quality measures as part of Meaningful Use. However, the Centers for Medicare and Medicaid Services (CMS), which administers the incentive program, says that the provision actually applies to something else.

In response to a query from InformationWeek Healthcare, a CMS spokesman said, "Our legislative staff indicates that the registry provision relates to the Physician Quality Reporting System (PQRC), not to the Medicare and Medicaid EHR incentive programs. The new provision allows physicians to participate in a qualified clinical data registry as a way to meet requirements for satisfactory reporting under PQRS."

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The PQRS regulation already allows physicians to submit quality data through a limited number of qualified registries and EHRs as an alternative to submitting special billing codes. But the CMS spokesman said, "The law gives the Secretary [of Health and Human Services] quite a bit of flexibility to establish the requirements for an entity to be considered a registry."

What this means, in practical terms, is that CMS will seek to define the term "qualified clinical data registry," the spokesman said, partly by soliciting outside comments. "Since this provision is effective beginning in 2014, it is likely we will be establishing these requirements through rulemaking later this year."

Over time, there could be broader implications, he added. "CMS is working to align PQRS with the clinical quality measure (CQM) component of the EHR incentive programs. So we will also be looking to see how the registry provisions may relate to the EHR incentive programs, given the connection with PQRS."

Up to now, PQRS has not been a roaring success. As of April 2011, when CMS last released figures on the program, a fifth of eligible professionals were participating in PQRS. Those who participated successfully received, on average, less than $2,000 each as a bonus, compared with an average payout of $3,000 in CMS' e-prescribing incentive program.

A big part of the problem with PQRS is the difficulty of using special billing codes to report the quality data, noted Jane Metzger, principal of the emerging practices group for the consulting firm CSC, in an interview with InformationWeek Healthcare.

Other observers agree. In a Medscape article, Bruce Bagley, M.D., medical director of quality improvement for the American Academy of Family Physicians (AAFP), said, "We're not recommending that anybody start with claims-based reporting to PQRS. It's just too cumbersome and clunky, it doesn't work well. If you're starting out now, you should go the registry route. Because it's a pretty low hurdle."

CMS has allowed some registry reporting to PQRS since 2008. For 2013, it permits reporting of various subsets of measures from more than 60 different registries, including some integrated into leading EHRs. But so far, this has not had the desired effect of significantly increasing physician participation.

One reason that the increased use of registries might not jump-start quality reporting, said Metzger, is that the reporting requires a large number of data elements that a particular EHR might not be able to generate or that might not be documented in discrete fields. So practices are still forced to have nurses or other clinicians gather the extra data and place it in a secondary database. A registry wouldn't eliminate that additional work, she said.

Whether or not the fiscal cliff provision is designed to jump-start physician participation in PQRS, it "requires the Comptroller General to study the potential of clinical data registries to improve the quality and efficiency of care in the Medicare program," according to the Congressional Research Service. So in the long run, the use of registries to improve healthcare might get a boost, as Orszag suggests.

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