Among all medical specialties, pathologists have a high rate of participation in both Medicare reporting programs

Many pathologists are aware of Medicare’s Physician Quality Reporting System (PQRS) and Electronic-Prescribing Incentive (e-prescribing) Program. But what is less known is that up to 40% of eligible doctors nationwide are opting to not participate and thus get paid less money from the Medicare program.

That high rate of non-participation is not true for one group of practitioners, however. Pathologists had the highest participation rate (78.7%) among specialties in PQRS and recorded the fourth-highest participation rate (80.3%) in the e-prescribing program! Pathologists received an average incentive of $246 for the 2013 e-prescribing program and $384 for the 2013 PQRS program.

CMS Data Shows Pathologists Have High Participation with PQRS Program

Those numbers are part of the Centers for Medicare & Medicaid Services (CMS) recently released 2013 Physician Quality Reporting System and E-Prescribing Incentive Program Experience Report. This report provides data on the growth of both programs designed to reward quality of care over volume and to advance the use of electronic health records.

In a fact sheet announcing the results, CMS highlighted the 47% jump in overall participation in the PQRS program from 2012 to 2013 and the 51% participation rate among the 1.25 million eligible providers. The e-prescribing program saw a 9% rise in participation in 2013 and a 47% overall participation rate.

CMS says the report indicates “progress in CMS’ efforts to improve quality measures and to encourage building a national electronic health information infrastructure in the United States.”

Fines Versus Compliance

Most news outlets, however, focused on the large percent of providers who choose fines over compliance. As reported in a Modern Healthcare article nearly 470,000 physicians and other eligible providers are receiving a 1.5% reduction in 2015 Medicare payments based on their quality-reporting data, while roughly 257,000 providers are seeing their Medicare pay cut 1% for not meeting e-prescribing program targets.

The most common reason for penalties was a refusal to take part. CMS says roughly 70% of non-participating providers treat fewer than 100 Medicare patients a year.

Pathologist PQRS Participation Slowing

While pathologists have high participation rates in the incentive programs, there has been attrition. The CMS report shows the number of pathologists participating in PQRS dropped from a high of 10,814 in 2011 to 10,799 in 2013.

Anders Gilberg, Senior Vice President, Government Affairs, Medical Group Management Association, speculates that some doctors find it less expensive to pay penalties for failure to comply with the Physician Quality Reporting System than hire additional staff to complete the paperwork, particularly if they treated few Medicare patients. He says the array of federal mandates doctors face “are not measures of physician quality—they’re more a reflection of the staff’s ability to code effectively.” (Photo copyright MGMA.)

Anders Gilberg, Senior Vice President, Government Affairs, Medical Group Management Association, speculates that some doctors find it less expensive to pay penalties for failure to comply with the Physician Quality Reporting System than hire additional staff to complete the paperwork, particularly if they treated few Medicare patients. He says the array of federal mandates doctors face “are not measures of physician quality—they’re more a reflection of the staff’s ability to code effectively.” (Photo copyright MGMA.)

A Wall Street Journal (WSJ) report quoted doctor groups as calling the array of federal mandates “confusing and time-consuming while offering little clinical benefit” and pointed to a 2104 Medical Group Management Association (MGMA) survey in which 83% of respondents said the programs detracted from their ability to care for patients.

“These are not measures of physician quality—they’re more a reflection of the staff’s ability to code effectively,” stated Anders Gilberg, Senior Vice President, Government Affairs for MGMA in the WSJ story. He speculated that some doctors found it less expensive to pay the penalties than hire additional staff to complete the paperwork, particularly if they treated few Medicare patients. As penalties increase, he said, some doctors might choose to not treat Medicare patients rather than comply.

Su Zan Carpenter, M.D., a family physician in Angleton, Texas, stopped participating in the Medicare program completely in October 2011 because the regulatory burden was getting to be too much.

“Every time you turn around, someone has a new rule or a new regulation or a new audit or a new something,” said Carpenter in a Texas Medicine Magazine article. “There’s a point where enough is enough. All that stuff was starting to get in the way of practicing medicine and helping people.”

PQRS Requirements Put Pathologists at Risk, Says CAP

The quality-reporting program began in 2007, using incentives to encourage providers to report on designated quality measures. Beginning in 2015, based on 2013 reporting, negative payment adjustments were implemented as required by the Affordable Care Act.

Pathologists are not immune from PQRS requirements, as the College of American Pathologists points out on its website:

“Participating in PQRS has been voluntary, but now is becoming mandatory if one wants to avoid Medicare payment penalties in the future. Pathologists are at risk of having Medicare payments reduced when CMS determines that they could have participated in PQRS and did not. Performance on PQRS measures in 2015 will be the factor deciding whether their Medicare Part B payments will have a negative PQRS and value-based modified (VBM) adjustment in 2017.

“While the CMS has said that the penalties will not apply for pathologists who have no applicable PQRS measures, the CMS plans to review claims to check that none of the measures applied. Eligible physicians face a 2% penalty in 2017 for not successfully reporting PQRS measures in 2015. PQRS also is a factor in the VBM, which also could penalize eligible physicians by an additional 2% to 4% in 2017 following the 2015 PQRS reporting year.”

The e-prescribing incentive/payment adjustment program ended in 2013, but electronic prescribing continues with Meaningful Use (MU).

AMA Outspoken Against “Regulatory Tsunami”

The American Medical Association (AMA) last year railed against the “regulatory tsunami” facing physicians who face Medicare reporting requirements and penalties under the MU program, PQRS, the value-based payment modifier (VBM), and the Sustainable Growth Rate (SGR) payment formula.

“The overlapping and often conflicting patchwork of laws and regulations must be fixed and aligned to ensure physicians are able to move to innovative payment and delivery models that could improve the quality of care,” said AMA President Steven J. Stack, M.D., in a December 2014 news release.

In April, Congress passed a new formula for calculating payments to providers who treat Medicare patients. The goal is to streamline the reporting programs and provide new incentives to doctors who move away from the traditional fee-for-service reimbursement system.

-Andrea Downing Peck

Related Information:

Lab Quality Confab Process Improvement Institute 2015

Participation Continues to Rise in Medicare Physician Quality Reporting System and Electronic Prescribing Incentive Program

Medicare-Provider Penalties, Incentives Detailed in Report

Leaving Medicare Tempting, But Possibly Costly

2013 PQRS and eRX Experience Report

Appendix: 2013 Reporting Experience Including Trends (2007-2014)

AMA Responds to CMS Regarding Meaningful Use Penalties for Eligible Professionals