Gastroenterologists' experience with the 2007 Physician Quality Reporting Initiative: a demonstration project.

In July 2007, the Centers for Medicare and Medicaid Services (CMS) launched the Physician Quality Reporting Initiative (PQRI), a voluntary program offering health-care providers an incentive bonus to report quality measures related to medical practice.1 In its inaugural form, PQRI did not require compliance with quality measures. Rather, it was designed to reward practitioners who simply reported whether or not they evaluated patients for specific measures, denoted as “pay for reporting.” The PQRI was established by the Tax Relief and Health Care Act of 2006,2 reflecting the U.S. government’s desire to see improvements in the health care delivered to Medicare beneficiaries. This was further evidence of a paradigm shift in how CMS thought of itself in terms of being a third-party payer. Replacing its historical function to passively pay for health care, CMS wanted to reward health care providers who make efforts to improve the quality of care they deliver, thereby gaining better value for every CMS dollar spent, a concept designated “value-based purchasing.”3 Of the 74 quality measures included in the 2007 PQRI, four related to gastroesophageal reflux disease (GERD) for gastroenterologists who wanted to participate. These measures were developed by the American Gastroenterological Association in conjunction with the American Medical Association’s Physician’s Consortium for Performance Improvement and adopted by the Ambulatory Care Quality Alliance (known as the AQA) for use by CMS.4 The four measures were: The percentage of patients aged 18 years and older with a diagnosis of GERD, seen for an initial evaluation, who were assessed for the presence or absence of the following alarm symptoms: involuntary weight loss, dysphagia, and GI bleeding. The percentage of patients aged 18 years and older with a diagnosis of GERD, seen for an initial evaluation, with at least one alarm symptom who were either referred for upper endoscopy or had an upper endoscopy performed. The percentage of patients aged 18 years and older with a diagnosis of GERD or heartburn whose upper endoscopy report indicates a suspicion of Barrett’s esophagus who had a forceps esophageal biopsy performed. The percentage of patients aged 18 years and older with a diagnosis of GERD, seen for an initial evaluation, who did not have a barium swallow test ordered. Health care providers participating in fee-for-service Medicare were to report additional Current Procedural Terminology (CPT) codes known as either CPT-II codes or “G” codes that corresponded to each measure as they applied to individual patients. Codes were included for both compliance and non-compliance with the measure (e.g. patients NOT assessed for alarm symptoms were also included). Exclusion-modifier codes existed for cases where providers felt particular patients did not fit the criteria indicated by the measures. This would enable a provider to report on every fee-for-service Medicare patient seen with specific GERD-related International Classification of Diseases, 9th revision (ICD-9) codes. Therefore CMS could determine both a numerator value (the number of Medicare patients for whom PQRI codes were reported) and a denominator value (the number of patients with specific ICD-9 codes reported on Medicare billing forms, and thus eligible for PQRI reporting). If this calculation demonstrated measure reporting by clinicians for at least 80% of eligible patients, the clinician had reported “successfully”. For clinicians to receive a bonus payment, they needed to report successfully on at least three measures applicable to their specialty. Therefore, gastroenterologists had to report on at least three of the four GERD measures. The bonus offered was 1.5% of total allowed Medicare part B charges, subject to a cap, and reflected patients seen between July 1 and December 31, 2007. The purpose of the current study was to assess the reasons for, ease of compliance with, and any pitfalls encountered by gastroenterologists participating in the 2007 PQRI program. The goal was to provide insight about PQRI to gastroenterologists considering future participation, as well as to inform feedback about the program to CMS.