PQRI's own quality problem

Health care quality. The phrase consists of only three simple words -- five short syllables. But when someone says them, they are saying a lot. And designing programs to move in that direction is no easy endeavor.

Take the Physicians' Quality Reporting Initiative. This effort, Medicare's physician reporting program, was established in the 2006 Tax Relief and Health Care Act. It was designed to encourage quality improvement through the use of incentives and clinical performance measures on a variety of conditions.

Both the goal and the process are of keen interest to the physicians and to the American Medical Association. The AMA has long been involved in promoting quality improvement. For instance, the AMA-convened Physician Consortium for Performance Improvement, first established in 2000, developed many of the program's clinical measures that the Centers for Medicare & Medicaid Services adopted.

The AMA also collaborated with the National Committee for Quality Assurance and other organizations to create tools to aid physicians in identifying measures relevant to their practices and to facilitate the data collection required to report clinical performance information.

But now, 11 months after the initial reporting period closed and just weeks away from the end of the 2008 reporting window, it is increasingly clear that steps must be taken if PQRI is to have a future as a meaningful tool for quality improvement.

A recent survey conducted by the American Medical Association, which generated 408 responses from physicians who participated in the 2007 PQRI, provided specific insights regarding what such a to-do list should include.

Based on those responses, 40% said their practice earned a bonus payment, 29% said they did not, and 31% did not even know. And in looking deeper inside these numbers, the program's challenges begin to emerge.

For starters, more than six in 10 physicians rated the program moderately, considerably or extremely difficult. This finding underscores one of the survey's key messages: In order to make the most of PQRI's quality improvement potential and encourage more physician participation, CMS should place a greater emphasis on early education and feedback. In regard to the latter, physicians reported significant difficulties in obtaining such information.

Only 22% of survey respondents said they were able to download their practice's PQRI feedback report. Of those who did, 59% rated their satisfaction with CMS' information and responsiveness as none to low. And, when asked an open-ended question about their overall participation, many physicians answered negatively, either saying they were discouraged by their PQRI experience or furious about the inability to find out why CMS considered their reporting efforts to be unsuccessful.

Meanwhile, program timing and other administrative elements also have emerged as urgent concerns.

Consider the following: Physicians who began reporting in July 2007 did not receive feedback reports until 12 months later -- halfway through the program's second year. This scenario made it impossible for participating doctors to have an opportunity to identify or fix reporting problems.

This shortcoming is now likely to be repeated with 2008 data.

All the while, physicians who were acting in good faith have no ability to appeal CMS' judgment.

Overall, these issues, many of which have been highlighted by both the AMA survey and a multitude of physician stories, show the areas in which CMS should begin to make changes.

The AMA is pressing the agency to rectify the various administrative issues that contributed to the program's difficulties. It also is urging Congress to put in place an appeals process to add an element of fairness, giving physicians a greater sense their reporting will be successful. The AMA also would like to conduct a detailed review of the 2007 data to better understand possible barriers and stimuli to physician reporting.

Policymakers must take needed action to maximize the program's quality improvement impact on physician practices and to increase physician participation. CMS' belief in the power of reporting should extend beyond the performance measures data the agency collects from doctors to include the AMA's findings regarding the need for improvements in PQRI.

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