Discovery of the JAK-2 kinase mutation in myeloproliferative disorders brought Janus, the two-headed Roman god, to the attention of all of us hematologists. Janus sits right in January — looking back to the past and forward to the future.
Looking back, it was wise in 2005 for the ASH leadership to engage in the evolution of the pay-for-performance process with the Center for Medicare Services (CMS) and, more recently, the AMA-Physician Consortium for Performance Improvement. Had ASH not engaged, others might have done this for us, or there might have been no metrics for hematologists created for inclusion in the new Medicare Pay-for-Reporting program to be implemented this July — in which case much of our clinical work would not count toward the planned bonus. We now participate regularly with the AMA-Physician Consortium via the ASH Practice Committee’s Hematology Workgroup, led by Steve Allen, MD, as well as through membership in the newly formed Oncology Workgroup.
Looking forward, ASH will be launching an online educational campaign in the spring with information about the 2007 Medicare Physician Quality Reporting Initiative (PQRI) program, hematology measures, and reimbursement. The financial incentive for the 2007 PQRI will be a lump-sum bonus payment in mid 2008 of 1.5 percent of allowed charges for covered professional services from July 1 to December 31, 2007, reported to the CMS National Claims History file by February 29, 2008. It is important to note that the 1.5 percent bonus will apply to allowed charges for all covered professional services and not just those charges associated with the specific measures reported on by clinicians.
Total charges, including the beneficiary deductible and co-payment, will be allowed — not just the 80 percent paid by Medicare or the portion covered by Medicare when Medicare is the secondary payer. PQRI-covered services are those paid under the Physician Fee Schedule only. A payment cap that will reduce the bonus below 1.5 percent of allowed charges may apply when an eligible clinician reports relatively few instances of quality measure data or under other circumstances. Eligible professionals in hematology practices will include physicians, nurse practitioners, physician assistants, and clinical nurse specialists. To be eligible, providers must use a National Provider Identification (NPI) on all claims and must successfully report on a designated set of quality measures.
The 74 measures finalized for Medicare are available on the CMS Web site. Modifications or refinements will be allowed up to the July 1, 2007, start date, but no new measures for 2007 will be accepted. Of eight measures directed toward hematology and oncology patients, four were developed by ASH. The four developed for solid tumors include one measure applicable to both hematology and oncology patients.
Reporting by hematologists for this initiative will be based on the claims-based quality reporting system used in the 2006 Physician Voluntary Reporting Program, which ended on December 31, 2006. Clinicians will report the CPT category II codes or, if these codes are not available, the appropriate G-codes. Successful reporting will depend upon how many quality measures are applicable to the services furnished by the hematologist during the entire reporting period. If no more than three measures are used by the clinician, each measure must be reported in 80 percent of the cases in which the measure was reportable. Clinicians will be able to select the quality measures that will be measured in their practices, but CMS is advising that clinicians report on every quality measure that is applicable to their patient populations to increase the likelihood that they will reach the 80 percent satisfactory reporting requirement and to decrease the likelihood that they will be affected by a cap on their bonus payment.
Stay tuned to the PQRI section of the ASH Web site for future updates. Details related to the cap will be particularly important to understand. Like Janus, we can look back to simpler times, but we must also look forward. For the sake of our patients, their families, and our practices, ASH intends to remain engaged in a sustained effort to positively influence the pay-for performance domain.
