On October 30, 2009, the Centers for Medicare and Medicaid Services (CMS) released the Medicare Physician Fee Schedule for calendar year 2010 for public display. In August, as part of the proposed rulemaking process, the Heart Rhythm Society submitted written comments on the proposed rule. In addition to addressing a range of payment policies that will impact the reimbursement and availability of physician services, this rule proposed changes to the Physician Quality Reporting Initiative (PQRI) and related quality reporting programs.
As detailed in the final rule, the new quality reporting policies will apply to services furnished to Medicare beneficiaries on or after January 1, 2010. The Society's health policy staff will conduct further review of the regulation.
Highlights of the 2010 PQRI Program
Bonus Payment
Eligible professionals (i.e. all professional paid under the Medicare fee schedule) will be able to submit quality data on either individual measures or measure groups. Eligible professionals who successfully report data will receive a 2 percent (of total allowed charges) bonus payment.
Reporting through Claims or Qualified Registry
Comments from the Society and other medical societies on the proposed rule recognized CMS’s willingness to transition to registry-based reporting and electronic health record-reporting with the caveat that, due to limited reporting options for some medical subspecialties, the timeline for adoption must be flexible. Acknowledging that its ability to reduce or eliminate its reliance on claims-based reporting is contingent on an adequate number and availability of registries and electronic health record reporting options, CMS will continue, in addition to the 12-month reporting period, to offer a 6-month claims-based reporting option for the PQRI beyond 2010. Maintaining its eventual goal to eliminate claim-based reporting, CMS may avoid introducing new claims-based measures and will increasingly limit the use of claims as a reporting mechanism.
Hospitals (not physicians) are currently rewarded for reporting in the ICD Registry™. The Heart Rhythm Society, the American College of Cardiology and National Cardiovascular Data Registry will be working with CMS to ensure that the ICD Registry is a qualified registry for PQRI, therefore that physicians are rewarded for reporting measures through the ICD Registry.
Interim Feedback Reports
The Society, along with other organizations, emphasized in its comments that CMS should assist physicians in their efforts to voluntarily participate in PQRI by providing interim feedback reports. CMS concluded that that it would be too burdensome to provide accurate participant-level interim feedback reports in an appropriately secure environment. However, registry-based reporting will require the registry vendor to provide one interim feedback report during the reporting period.
In the health care reform legislations currently making its way through Congress, refinements to the PQRI program such as timely feedback to provider are included.
Due Process Protections
The Society's written comments emphasized the request for a timely appeals process for PQRI. In the final rule, CMS responded that the statute guiding this regulation does not provide for administrative or judicial review. The current health care reform legislations will require CMS to modify the PQRI Program to include a transparent appeals process.
Criteria for Satisfactory Reporting of Individual Quality Measures
In response to comments on criteria for satisfactory reporting of individual quality measures, CMS determined that it would not adopt its proposed reporting criterion that the minimum patient sample size for reporting individual quality measures be 15 Medicare Fee for Service (FFS) during a 12-month period. CMS did not incorporate the minimum patient sample requirement because it would adversely impact a significant number of eligible professionals with small practices, limited number of Medicare patients or patients with rare diseases. CMS will reconsider adding the minimum patient sample requirement in the future when it has more data on PQRI.
Individual Quality Measures
As in 2009 and as detailed in the proposed rule, measures will be reported through claims or a qualified registry, with some measures only reported through a qualified registry or electronic medical record (EHR). Electrophysiologists are eligible to report on the following measures:
| Measure Number | Measure Title | Reporting Mechanism |
| 6 | Oral Antiplatelet Therapy Prescribed for Patients with Coronary Artery Disease (CAD) | Claim & Registry |
| 20 | Perioperative Care: Timing of Antibiotic Prophylaxis -Ordering Physician | Claim & Registry |
| 22 | Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedure) | Claim & Registry |
| 30 | Perioperative Care: Timing of Prophylactic Antibiotics -Administering Physician | Claim & Registry |
| 45 | Perioperative Care: Discontinuation of Prophylactic Antibiotic (Cardiac Procedures) | Claim & Registry |
| 46 | Medication Reconciliation: Reconciliation after Discharge from an Inpatient facility | Claim & Registry |
| 55 | 12 Lead Electrocardiogram (ECG) Performed for Syncope | Claim & Registry |
| 76 | Prevention of Catheter-Related Bloodstream Infection: Central Venous Catheter Insertion Protocol | Claim & Registry |
| 124 | Health Information Technology: Adoption/Use of Electronic Health Records (EHR) | Claim , Registry & EHR |
| 130 | Documentation and Verification of Current Medications in the Medical record | Claim & Registry |
| 5 | Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | Registry & EHR |
| 7 | Coronary Artery Disease: Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction | Registry & EHR |
| 8 | Heart Failure: Beta Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | Registry |
| 33 | Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation at Discharge | Registry |
| New in 2010 | Heart Failure: Left Ventricular Function Assessment | Registry |
| New in 2010 | Heart Failure: Warfarin Therapy Patients with AF | Registry |
Group Practice Reporting
The Society's comments on the proposed rule acknowledged the value of group practice reporting measures to encourage voluntary reporting and promote better care coordination, but also commented that the measures are primarily focused on high-cost chronic conditions and preventive care. Although commenters encouraged CMS to consider strategies that would allow small physician groups to participate in this reporting option, CMS defined a group practice as a group of at least 200 or more eligible physicians.
The final rule formalized this reporting process of 26 NQF endorsed quality measures including four measures relevant to electrophysiologists. These measures were also included in the 2009 PQRI:
| Measure Number | Measure Title |
| 1 | Diabetes Mellitus: Hemoglobin A l C Poor Control |
| 2 | Diabetes Mellitus: Low Density Lipoportein Control |
| 3 | Diabetes Mellitus: High Blood Pressure Control |
| 5 | Heart Failure: ACE Inhibitor or ARB Therapy for LVSD |
| 6 | Oral antiplatelet therapy prescribed for patients with coronary artery disease |
| 7 | Coronary Artery Disease: Beta-blocker therapy for coronary artery disease patients with prior myocardial infarction |
| 8 | Heart Failure: Beta-Blocker Therapy for LVSD |
| 110 | Preventive Care: Influenza Vaccination for Pateints>50 years |
| 111 | Preventive Care: Pneumonia Vaccination for Patients 65+ years |
| 112 | Preventive Care: Screening Mammography |
| 113 | Preventive care: Screening Colorectal Cancer |
| 117 | Diabetes Mellitus: Dilated Eye Exam |
| 118 | Coronary Artery Disease: ACE/ARB for Patients with CAD and Diabetes and.or LVSD |
| 119 | Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy |
| 163 | Diabetes Mellitus: Foot Exam |
| TBD | Diabetes Mellitus: Hemoglobin A l c testing |
| TBD | Diabetes Mellitus: Lipid Profile |
| TBD | Heart Failure: Left Ventricular Function Testing |
| TBD | Heart Failure: Left Ventricular Function Assessment |
| TBD | Heart Failure: Weight Management |
| TBD | Heart Failure: Patient Education |
| TBD | Heart Failure: Warfarin Therapy for Patients with AF |
| TBD | Coronary Artery Disease: Drug Therapy for Lowering LDL-Cholesterol |
| TBD | Preventive Care: Blood Pressure Management |
| TBD | Hypertension: Blood Presure Control |
| TBD | Hypertension: Plan of Care |
It is important to note that individuals who participate in the group practice reporting option will not receive a separate bonus payment as individual eligible professional.
Despite concerns about the readiness of this program for public reporting, CMS asserted that public reporting of group practice performance results provide an opportunity to move towards greater public reporting and transparency. As a compromise, CMS will not require group practice to have their PQRI performance results publicly reported in 2010.
NQF endorsement
As noted in the proposed rule, in 2010 and in subsequent years, the quality measures must be endorsed by the National Quality Forum (NQF), with limited exceptions defined by the Secretary of Health and Human Services. The Society is supportive of this change. The statutory requirement does not specify how the measures are submitted to NQF providing a potential opportunity for sub-specialty medicine to propose “high-impact on healthcare” measures for review by the NQF; particularly when there are gaps in the PQRI quality measures where eligible providers do not have at least 3 measures applicable to their practice.
