On April 9 CMS released information on Medicare’s 2011 Incentive Payment awardees for high quality and e-prescribing. APRN winners increased at a faster rate than observed for MDs/DOs for both quality and eRx. Both programs experienced a scheduled cut in the incentive payment percentage (from 2% to 1%) in 2011. Nonetheless, the APRN eRx incentive winners more than doubled increasing total incentive payments to APRNs by 38% (compared to a 6% increase for physicians.)
The Physician Quality Reporting System (PQRS) provides incentives for Medicare clinicians who achieve high marks for quality. The quality bonus program was first implemented in 2007. This program was designed to encourage eligible professionals to report on clinical quality measures by providing payment incentives. Those incentives are based on a percentage of the total estimated Part B Medicare Physician Fee Schedule (MPFS) allowed charges for services provided during the reporting period. The total number of all PQRS incentive recipients increased 37% over the prior year. In fact, the number of APRNs who won awards increased by 43%, going from 16,815 in 2010 to 23,979 in 2011. The increase in the number of certified nurse-midwives who received PQRS incentive payments was 68%. Although APRNs represent just 9.6% of Part B providers, they were 10.6% of the PQRS award winners. Total approved charges for all APRN services in 2011 were 1.9% of the Part B total. APRNs earned 2.1% of all PQRS incentive payments.
Distribution of Incentive Amounts for the Physician Quality Reporting System
Total incentive payments
% of Total
Certified Nurse Midwives
Clinical Nurse Specialists
The eRx incentive program derives from Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), introduced in 2009. Similar to PQRS the eRx incentive program provides direct financial incentives to encourage eligible professionals to switch from paper to electronic prescribing. The number of APRNs who received eRx incentive payments more than doubled, going from 3217 to 7680. The number of NP winners increased by 140%. CNMs did not earn a substantial amount of incentive payments, just $1488. However, because the awards are based on approved charges and the Affordable Care Act increased CNM approved charges from 65% of the MPFS to 100%, the increase in CNM awards was 342%.
Distribution of Incentive Amounts by Specialty for the eRx Incentive Program
While the APRN share of quality bonuses was somewhat higher than their share of total approved charges, the APRN share of e-prescribing bonuses was much lower, 1.1%. This suggests that APRNs’ prescribing patterns may not be comparable to those of physicians—the backdrop for the CMS assumptions for implementing the penalty phase of MIPPA. Specifically, eligible professionals who provide at least 100 office visits but do not order a sufficient number of electronic prescriptions for their Medicare patients are subject to across the board reductions in their Medicare allowances. Among APRNs, only NPs were subject to this part of the MIPPA incentive scheme, as a result of the HHS Secretary’s finding that NPs had prescriptive authority in each of the 50 States. In part due to ANA’s efforts, CMS created an exemption for “limited prescribing activity,” clinicians who wrote fewer than 10 prescriptions in 2011. (That threshold was increased to fewer than 100 e-prescriptions for 2012 and thereafter.) That exemption is not automatic; NPs (and all other clinicians who provide 100 or more Medicare office visits in one year) who want the exemption must apply online to CMS. Sadly, 9051 NPs were subject to a one percent reduction in Medicare allowances in 2012.
The only reduction in eRx awards was observed for CRNAs. In both 2009 and 2010 there was one incentive payment made to a CRNA. There had been no information on whether it had been the same CRNA practice that won both awards, no information on the State or States where the award winner(s) practiced. There was no CRNA eRx award winner for 2011. This may reflect the brouhaha that developed late in 2010 when a Medicare Carrier Medical Director (who happened to be an anesthesiologist) made a local coverage decision that disallowed CRNA pain management as a covered service. The original national Medicare policy including pain management as a CRNA service was restored with the implementation of the 2013 Medicare Fee Schedule in January 2013.
Last year I began my first posting to One Strong Voice, impressed that the sum of the two sets of APRN awards for 2010 was $9,095,434.29. The 2011 total is somewhat lower, $8,167,566.79, a reduction of almost $1 million. That, however, is the result of the change in the payment formula. Were it not for that reduction the total of the APRN awards would have come to $16,335,134, an 80% increase over the prior year. I remain impressed.