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Dynamic Chiropractic – April 22, 2011, Vol. 29, Issue 09
Dynamic Chiropractic
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Dynamic Chiropractic

Medicare and the Chiropractic Practice, Part 9

The PQRI – looking beyond the 1% incentive bonus.

By Ritch Miller, DC

In our last article [March 26], we noted that the passage of the Patient Protection and Affordable Care Act (PPACA) made the Physician Quality Reporting Initiative (PQRI) program permanent and that those not reporting by 2015 will have their Medicare reimbursement decreased.

As the program is now here to stay, the name of the program has been changed to reflect that permanency. The PQRI will now be referred to as the Physician Quality Reporting System (PQRS).

When some doctors are asked why they don't participate in PQRS, formerly PQRI, many simply say the 1 percent incentive bonus just isn't worth the trouble. With all of the stresses and responsibilities facing doctors of chiropractic in our changing health care environment, it is not difficult to see why many may have this attitude. Furthermore, with doctors already concerned with Medicare audits, some are worried that participating in PQRS will just draw unwanted attention from CMS and its contractors, leading to additional audits.

Providers should understand that the audits performed thus far with regard to PQRS have not included any type of financial penalty; rather, providers have actually been reimbursed for participating in PQRS audits. The audits being conducted have been solely focused on determining if changes need to be made to the measures' descriptions to ensure accuracy in reporting.

Although some providers may have many reasons why they don't want to participate in PQRS, what must be remembered is that quality reporting goes far beyond incentive bonuses and Medicare. Quality reporting is here to stay. The federal government has funded efforts to support quality measurement reporting, ensuring that reporting will remain a requirement long after PQRS incentive bonuses are offered. In the coming years, quality reporting will also help to provide more data on how different provider types and different facilities compare in treatment of patients.

Currently, the major quality reporting initiative operates through the PQRS program. The measures that are being reported focus on process and structure. For example, one measure focuses on whether a doctor has performed a pain assessment (process measure) while another focuses on whether the provider has used an electronic health record (EHR) in their clinic (structure measure). In the future, there will be greater emphasis on measures that focus on outcomes. For example, the National Quality Forum developed, and continues to create, measures that will provide the public with more information regarding the quality of a hospital, the types of conditions managed and the outcomes of different treatments. One measure in development is the Acute Myocardial Infarction (AMI) Mortality Rate measure. This measure will provide hospital-level data.

First convened in September 2007, the Chiropractic Summit represents leadership from some 40 organizations within the profession. The Summit meets regularly to collaborate, seek solutions, and support collective action to address challenges with the common goal of advancing chiropractic.

A major focus of the Summit is to improve practitioner participation, documentation, and compliance within the Medicare system. This article, the ninth in a series developed by the Chiropractic Summit Documentation Committee, is a continuation of part 8's discussion of the Physician Quality Reporting Initiative.
As a reminder, quality measures are made up of numerators and denominators. For the AMI measure, in the numerator, the number of inpatient deaths from all discharges who are 18 or older with a principal diagnosis of acute myocardial infarction will be listed. In the denominator, the number of all discharges ages 18 or older with a principal diagnosis of acute myocardial infarction will be listed. Ultimately, this measure will provide data on the number of deaths per 100 discharges with a principal diagnosis code of acute myocardial infarction.

If a hospital were to have a very high number of deaths per 100 discharges compared to other hospitals, this would be valuable information for the public to have. This information will also help hospitals and providers to evaluate the care they provide and the processes they have in place, especially if they are found to have very high mortality rates compared to other facilities.

Eventually, outcome measures will be developed that capture data on the conditions doctors of chiropractic manage. This data will be helpful in comparing the care provided by DCs with that of other health care providers managing the same conditions. Quality measures data could ultimately demonstrate what doctors of chiropractic have long understood: Care provided by DCs is efficacious and cost-effective compared to other forms of care.

Quality measurement and reporting is being weaved into every aspect of our health care delivery system. For example, as part of the criteria for obtaining an incentive bonus under Medicare's EHR incentive program, clinical quality measures' results (numerators, denominators and exclusions) must be reported to CMS. The Patient Protection and Affordable Care Act also underscored the importance of quality measure reporting by mandating that CMS develop a plan for integrating the PQRS and the EHR incentive programs by Jan. 1, 2012.

Given the far-reaching effects of quality reporting, it is recommended that doctors of chiropractic begin participating in PQRS. Until 2014, bonuses will be provided for successful participation and, because quality reporting is going to be a standard part of any health care provider practice in the coming years, it is beneficial to start participating now so that your clinic can develop protocols for reporting.


The members of the Summit Subcommittee on Documentation are Dr. Carl Cleveland III, Ms. Kim Driggers, Dr. Farrel Grossman, Dr. Salvatore La Russo, Dr. John Maltby, Dr. Peter Martin, Ms. Susan McClelland, Dr. Ritch Miller, Dr. Frank Nicchi, Mr. David O'Bryon, and Dr. Frank Zolli. As with previous articles, Dr. Miller served as principal author of this article, with assistance from the documentation working group and significant contributions by Ms. Kara Murray, ACA director of federal & regulatory affairs.

As noted in part 8 of this continuing article series, CMS provides helpful PQRS resources, accessible at www.cms.gov/pqri. The CMS Web page provides detailed information about quality measures, frequently asked PQRS questions, and news / updates. CMS also regularly holds national provider conference calls focused solely on PQRS, with general updates and the opportunity for health care providers to ask questions regarding PQRS procedures. In addition, the CMS' PQRS helpdesk may be reached at 1-866-288-8912 or by e-mail at . The ACA also provides tools to get started with PQRS reporting. These resources refer to only the measures applicable to DCs and are available online at www.acatoday.org/pqrs. The ACA also stands ready to assist providers with questions; e-mail the ACA's Government Relations Department at .


Dr. Ritch Miller is a member of the Chiropractic Summit Subcommittee on Documentation. Other members are Dr. Carl Cleveland III, Dr. John Maltby, Ms. Susan McClelland, Dr. Peter Martin, Mr. David O'Bryon, and Dr. Frank Nicchi. Dr. Miller served as principal author of this article, with contributions from members of the subcommittee.

Dynamic Chiropractic

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