Texas physicians face Medicare payment cuts after the government health care payer made technical mistakes in its new, complex quality reporting programs doctors must follow.  The Centers for Medicare & Medicaid Services (CMS) set up the Physician Quality Reporting System (PQRS) and value-based payment modifier programs so physicians who report health care quality data to the agency can assess the quality and efficiency of their medical care.  Ideally, government feedback reports would identify gaps in care and improve performance, for better care and reduced costs for patients of doctors.  Medicare pays under its fee-for-service model.

Instead, doctors say, a government glitch is costing physicians money and time. At least one-quarter of participating physicians face the pay cut, according to one estimate.

Texas Medicine magazine reports some physicians received notice last fall that CMS had technical difficulties calculating data and that up to 4 percent of their 2016 Medicare income would be cut. Doctors might stop the cut only if they appealed their payment penalties. Medicare payments are based on health care quality performance data submitted by physicians two years earlier. For example, 2016 payments are calculated from data collected in 2014.

The potential Medicare payment cuts are especially troubling to Lubbock family physician Michael Ragain, MD, who invested in an electronic health record (EHR) system and adjusted his business practice to capture and submit performance data to CMS. He feels he properly complied with the government plan, only now to suffer the consequences of the government’s mistake.

“If I make an error in my practice, I have to tell the patient and take responsibility and often write off the charges associated. They [Medicare] make an error, and I have to appeal or I get a penalty, plus [pay] the expense of the EHR to do the reporting. It’s frustrating, and it’s not fair,” Dr. Ragain said.

What happened?

CMS provided performance feedback that was difficult for physicians to interpret, and CMS’ recalculation of some data resulted in lower performance scores for many physicians, putting them at risk for payment cuts in 2016. Medicare has yet to further explain the reason for the glitch or how widespread the problem reaches, saying only, “there were issues with data submitted” and “a technical issue.” But physicians say the damage is done, the pay cut threat remains, and much of doctors’ time has been wasted. The Texas Medical Association (TMA) and the American Medical Association pushed CMS to extend the deadline for physicians to appeal. CMS did extend the deadline — one month — to December 2015. CMS first revealed the mishandling of the performance data the month before, in November.

In a December 2015 letter to Texas’ congressional delegation, TMA President Tom Garcia, MD, said on the association’s behalf, “[We are again] seeking relief from some ridiculous edict from the CMS. They’ve done it again, and so I return with this entreaty. The latest victims are those physicians who are actually trying to comply with CMS’ convoluted pay-for-performance rules.” TMA wanted CMS not to penalize physicians who tried to participate in the program, or at least extend doctors’ appeal deadline into 2016. Neither occurred.

Here’s one example of the bureaucratic problem doctors face: Last year, CMS accused several TMA physicians of incorrect reporting, and denied their final incentive payments. It turns out CMS renumbered a measure related to coronary artery disease. The measure doctors were to follow did not change, but the number did. Physicians did right, but the number was now wrong. Physicians successfully appealed and updated their submissions, but Medicare only agreed not to penalize them; the agency refused to pay doctors for correctly meeting the performance measure.

“I certainly aspire to be high quality and care very much about my outcomes with patients. And most doctors want to provide high quality, and if they get data that’s understandable, they will modify their behavior to do better,” Dr. Ragain said. But Medicare has to do its part, too, he said.

CMS reports as of December 2015, there are 1,390 doctor groups with at least one PQRS or value modifier informal review (appeal) pending. TMA won’t be able to gauge the full impact of the Medicare pay cuts in Texas until CMS releases its annual PQRS report later this spring.

TMA is the largest state medical society in the nation, representing more than 49,000 physician and medical student members. It is located in Austin and has 110 component county medical societies around the state. TMA’s key objective since 1853 is to improve the health of all Texans.

Contact:  Brent Annear (512) 370-1381; cell: (512) 656-7320; email: brent.annear@texmed.org

Marcus Cooper (512) 370-1382; cell: (512) 650-5336; email: marcus.cooper@texmed.org

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