This is the main Medicare building - I was so excited about visiting Medicare that I forgot to keep my finger away from my lens.
Medicare headquarters are at 7500 Security Boulevard in Baltimore. And they mean security :-) Your car will be thoroughly inspected before entering the parking lot. Then you enter the building and you go through an airport style inspection, with the additional step that they check your laptop id. Then someone escorts you to your final destination.
Inside the main auditorium we finally met Dr. Daniel Green and all his PQRI team.
He put us at ease with his sense of humor - he is an Ob/Gyn doctor, his wife practices internal medicine in the state with the "worst reimbursement rates" in the country and they just bought a pregnant horse last week. Supposedly he also owns a mini-donkey but we are not sure if he was serious about that :-)
These are some of the highlights of the meeting:
- 74 registries qualified this year. Last year there were 32 Medicare qualified registries. 31 sent data. These registries sent PQRI Quality data regarding 10000-99999 patients. They are not sure about the actual numbers yet.
- CMS is working hard to make sure that physicians that reported data can get their 2% reward over their Medicare charges. One of the problems is that sometimes the TIN (tax id number) submitted by the physician has no actual Medicare charges because it is the wrong one (2% of $0.00 is $0.00). Many physicians have several TINs - To avoid this problem - physicians need to be reminded by registries to always use the one they use to submit data to Medicare. I think they have 300 physicians with "wrong" TINs.
- As a aside I have an hypothesis regarding why physicians sent the "wrong" number. In the past I had physicians that requested P4P money from insurances companies to be sent to their personal TINs because they would like the money not to go to the physician group. For example if a doctor works in a group with other 10 physicians that share the same group TIN and this doctor decides to submit PQRI data individually, he/she may hope that the PQRI reward to return to him/her so then he/she tries to send the individual tax id for the PQRI. Unfortunately there are no Medicare charges with this individual TIN - so no reward. DOCTOR - ALWAYS GIVE THE TIN YOU USE TO BILL MEDICARE
- Some registries submitted data in the name of medical residents - big mistake. Always use the attending NPI and TIN.
- Providers can sign electronically the doc authorizing registry to submit data to CMS if state law allows it - I am not sure which states don't allow electronic signatures - I sign electronically all the time when I open a new bank account...
- The quality measures should match the specialists - Technically you can report on diabetes for orthopedic surgeons but that's not the idea behind the PQRI.
- Once a registry gets approved for one specific PQRI measure tag (Procedure, Episode, Patient - Process, etc) it can ask permission by email to add another PQRI measure of the same type. For example if a registry is approved for Measure #176 Rheumatoid Arthritis (RA): Tuberculosis Screening that has type "Patient-Process", it can request to be approved for another measure of similar type like 127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear.
- There will be monthly conference calls with the registries. If a registry misses one call, it will be forgiven. If a registry misses two monthly support calls, it will not qualify anymore - the registry will turn into dust...
- Providers submitting PQRI data with claims and registries will be paid using the most favorable method. CMS will not combine methods.
- Two IACS accounts per registry are necessary to submit data. One will be for backup. The actual submission will be done through the PQRI Portal using the IACS authentication. You can submit test data and there is a feedback email that tells the registry if the XML file has the correct format.
- The way we were tested during the registry vetting process using a 4GB DVD to send an encrypted 10k XML test file to CMS was just a test...
- Central Utah registry talked about their PQRI experience. Some of their providers wanted to complicate things and add extra measures. Also suggested that contracts to be signed by the doctors should be easy or else it will scare them. Their physicians signed all authorization forms online. Central Utah reminded everyone to be sure that the right combination TIN/NPI is used by each provider.
- CINA, another 2008 qualified registry reported on 360 providers. CINA reminded us that PQRI measures are not created equal. For example some dialysis measures are reported per month. Be careful with the formal measure type (tag). CINA mentioned that providers got very engaged when they see their reports. Also suggested registries to enter TIN and NPI electronically to avoid errors. However, Dr. Green mentioned earlier that some providers on some registries got "too engaged" regarding their performance reports and didn't want to submit their data to CMS because they thought their performance scores were low. Reminded registries that for now providers will be paid by reporting and not by performance.
- Docsite registry submitted data from ~ 2200 providers. Docsite noticed that doctors got confused with the 30 consecutive patients concept despite being explained a lot on their website. Docsite found the AMA worksheets very useful. Again remind doctors - NPI and TIN use the ones you use to bill Medicare.
- During the meeting, lots of questions regarding the new XML tag encounter-from date and encounter-to-date . CMS wants encounter dates but they may change where they place this tag - one registry suggested to place this XML tag at the level of the provider and Dr. Green thought that idea is very reasonable. The "final 2009" XML specs maybe will not be so final.
- One registry mentioned the 18MB file limit on XML file to submit on the PQRI portal. I didn't understand why this was a problem. Probably with 18Mb we could report PQRI on all doctors on planet Earth... Anyway registries can submit multiple XML files.
- Next year providers can request their PQRIs reports from their respective Medicare carriers and they will be sent to the provider's email.
- This year you can submit more than 100 providers in one XML file.
- You can resubmit PQRI XML data from the same provider again if there is a correction. Last updated data will replace the old one on the CMS PQRI datawarehouse.
- Payments for PQRI 2008 are only coming in the Fall of 2009.
- Dr. Green mentioned that the new proposed PQRI rules for 2010 were published today on the Federal Registry. You can find a summary here and you can read the full rules here. CMS will accept comments on the Proposed Rule until August 31, 2009. "The Proposed Rule is scheduled to appear in the Federal Register on July 13, 2009" - from a good place to get Medicare updates - http://medicareupdate.typepad.com/medicare_update
- One registry commented that it is kind of hard to read the Federal Registry everyday and he would like some kind of summaries to be sent to registries regularly. Dr. Green mentioned that will be one of the functions of the monthly calls.
- I talked with Shiby Thomas from the Boston Medical Center PQRI registry. He mentioned that he had some difficulties implementing the rules for measure #159 - HIV/AIDS: CD4+ Cell Count or CD4+ Percentage - it needs to be done twice a year. CMS worked with measure owner and revised the rule.
- Another registry mentioned that in the foot exam for diabetes there was a rule that required 5 components on this exam but CMS supposedly thinks that 2 components are enough. Other registries were not aware of this change
- I suggested that the registries should create a user group to share their experiences, exchange tips and new information. Dr. Green liked the idea. He is going to collect emails from registries interested in this. In meantime I am suggesting to use twitter with the tag #pqri to post comments during this conference and even after. Registries could also use blogs to share their experiences and support each other efforts. Another suggestion - create a PQRI user group wiki. Someone suggested a facebook PQRI group page where everyone could get updates.
My final impression is that the hard working PQRI CMS team is very transparent, open-minded and looking forward to collaborate with all our registries to improve the quality of care in the US.
As an example of registry collaboration - I ended the day with a dinner at the Inner Harbour paid by the registry Outcome (thanks FX Campion!!) and enjoying the view of the beautiful National Aquarium in Baltimore.
If you have a Diabetic Foot Problems you can contact Dr. Amit Bhargava. Dr. Amit Bhargava is a an internationally trained senior Orthopedic Specialist.
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