PQRS: A Quality Vaccination for Behavioral Healthcare

By Paula E. Hartman-Stein, Ph.D.
March 31, 2015

PQRS: a quality vaccination for behavioral healthcareThe hue and cry among many psychologists notified of a 1.5 percent reduction in payments from the Centers for Medicare and Medicaid (CMS) this year as a penalty for not participating in a government quality assurance program is perhaps understandable given the tight finances of most practices.

But there have been ample warnings that changes connected to the Physician Quality Reporting System (PQRS) were coming, including the penalties that will grow to 2 percent next year for non-participants.

Some psychologists who knew about the penalties chose not to participate, criticizing its relevance and viewing it as a conspiracy against mental health practitioners. A brief history might give some perspective.

Crossing the Quality Chasm: A New Health System for the 21st Century, published in 2001, is an early publication that aligned incentives in healthcare payments to accountability and called to close the quality gap between research evidence and practices of care.

In 2004 the Ambulatory Care Quality Alliance (AQA), a national coalition of more than 135 organizations, formed to improve healthcare quality.

In December 2006, health economist Jim Hahn informed Congress for the need to align payment with quality rather than quantity of services due to the projected growth in Medicare over the next 40 years. Also in 2006 the Institute of Medicine (IOM) called for variable physician payments based on quality. At that time there was no infrastructure for clinicians to report what they did and no measures of quality of care.

On Dec. 20, 2006 President George W. Bush signed the Tax Relief and Health Care Act that authorized a quality reporting system by CMS to reward clinicians if they met reporting requirements, giving birth to PQRS, initially called the Physician Quality Reporting Initiative (PQRI).

An article in the Journal of the American Medical Association (Oct. 17, 2007) gave momentum to quality reporting by noting the public’s interest in healthcare quality but still no standardized or consistently accurate quality measurements existed. CMS then hired contractors such as Quality Insights of Pennsylvania that formed panels of professionals to create and modify “measures” that are similar to best practices.

The number of measures has grown from 73 in 2007 to 287 in 2014, with 40 measures retired in 2015. The rules change over time, but in 2015 providers must report on nine across at least three public health domains (if there are nine available based on CPT codes).

PQRS initially offered small financial incentives to encourage buy-in. The highest bonus was 2 percent for reporting three quality measures on 80 percent of eligible patients in 2009 and 2010.

In March 2007 CMS convened a panel for Psychology and Social Work to develop three “best practices.” I became chair, appointed by APA Division 12, Clinical psychology, because of my work in 1990 on the Resource-Based Relative Value Scale study at Harvard that determined reimbursement.

The committee consisted of two other mental health practitioners and a nurse with a master’s in public health. The initial measures were screens for depression and cognitive impairment and the motivational interview technique of getting the patient’s acceptance of a treatment plan.

At a historic meeting of the AQA in October 2007, representatives from commercial insurance companies and the AMA engaged in a vociferous debate. The AMA stance was that “best practice” measures should reflect basic competencies of healthcare that fill gaps of care based on research. Commercial payers advocated for “aspirational measures” that would supposedly raise quality a few notches. The AMA and non-MD providers were allies on this point and the AMA stance prevailed. At the meeting all specialties were created equal and voted on all 73 proposed measures. Because of the vote at that meeting, psychologists, social workers and physical therapists were included in the bonus system in 2008.

In the past seven years, measures have come and gone, more expert panels have appeared with financial penalties arriving in 2015. Besides the financial carrot and stick process, pressure to participate began in another way in 2014 with the creation of the Physician Compare website. All providers who accept Medicare payments can find their name on this public site in addition to address, gender, year of graduation from a doctoral program, and notice of PQRS participation in 2013. In the near future quality ratings will be published for individuals and group practices.

Who’s to blame for so many not anticipating the penalties or the website data? Is it the individual practitioners for not staying abreast of the growing quality movement in healthcare? Is it their professional associations for not alerting them sufficiently? Or is it CMS itself for burying PQRS notices in a mountain of other bureaucratic notices?

Who gets the blame really doesn’t matter. Those who didn’t get an early start in PQRS should begin catching up immediately because PQRS or another iteration is here to stay.

Some psychologists who have been aware of the carrot-stick system chose to forego participation in PQRS because the money involved was small potatoes in the grand scheme. But is that all that counts?

Whether we think participating in PQRS improves the quality of care of our patients or not, the government and third-party payers think so. The Department of Health and Human Services announced in January 2015 the goal of tying 85 percent of all fee-for-service payments to quality and cost measures by 2016 and 90 percent by 2018.

The question of participation in the quality movement in U.S. healthcare has principles similar to those found in the vaccination debate. We vaccinate our children not only to protect their health but also for the health of the children around them. Some PQRS measures have been created to increase the safety and health of the population as well as lower costs. Screening for and educating about weight, smoking, elder abuse, pain, what meds a person is taking and mood are aspects of behavior patterns that keep people healthy, out of hospitals and maybe even needing less meds. What a concept! Aren’t psychologists supposed to help their patients have healthier life styles, not just deliver protocols to treat mental health symptoms?

If neither financial penalties nor performance ratings are sufficiently motivating to participate in PQRS, consider whether you have any responsibility to improve the overall health of your patients and prevent medical problems via life style changes, similar to an immunization but without chemicals. If the answer is yes, then participate in PQRS, a flawed system that is bound to improve and someday may even come close to measuring quality of care.

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