Quality reporting plan: AMA tells CMS to scrap flawed program

Delegates laud the strong opposition to the voluntary CMS system while pushing hard for dedication to pay-for-performance principles in lobbying efforts.

By David Glendinning — Posted Nov. 28, 2005

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Dallas -- The American Medical Association earlier this month hit the White House's precursor to Medicare pay-for-performance with a potentially fatal blow before the initiative had even gotten off the ground. Physicians at the Association's Interim Meeting praised what they described as a bold move aimed at protecting doctors' practices.

The entire AMA Board of Trustees signed a Nov. 3 letter condemning the Physician Voluntary Reporting Program, which the Centers for Medicare & Medicaid Services released with much fanfare less than a week earlier. The plan, which would give doctors the opportunity starting in 2006 to report to the government how well they fare on a number of quality measures, is effectively dead on arrival, AMA leaders said.

"We have serious concerns regarding the PVRP and its ability to achieve its stated quality goals," reads the letter to CMS Administrator Mark McClellan, MD, PhD. "The excessive administrative requirements that this program will impose on physicians could doom this initiative and negate any intended quality improvements."

The trustees are calling for CMS to rescind the entire plan and start over, rather than take steps to repair it.

While the voluntary program does not yet incorporate true pay-for-performance, the Bush administration has made no secret of its intention to use the initiative as a springboard for an eventual payment system based on how well doctors score on the quality measures. Following the unveiling of the trustees' letter, delegates passed, with virtually no dissent, a resolution echoing the board's concerns.

The Association's leaders sought to respond swiftly and forcefully to the voluntary program's announcement because CMS took few of the AMA's considerations into account in its rush to develop the plan, said AMA Trustee Cyril M. Hetsko, MD.

"This was something too quickly and too poorly thought out," he said.

Physicians who would participate in the program starting in less than two months, for example, would be expected to learn scores of new "G" codes to report quality measures to the government. This administrative load would be overwhelming for most practices, especially those without sophisticated information technology systems, doctors said.

"To expect physicians who are already under the gun to see many patients per hour and then to sit down and work out this voluntary reporting and develop new codes for our systems ... this would be a tremendous burden," said Joseph Zebley, MD, who is a delegate from the American Academy of Family Physicians.

In addition, some of the measures on which doctors would be judged do not even make sense in the outpatient setting, Dr. Hetsko said. Administration of aspirin and beta-blockers for arriving heart attack patients, for instance, are appropriate for hospital emergency departments but not for physicians' offices.

Dr. Hetsko told delegates that trustees were so "incensed" about the voluntary reporting program that they prompted Dr. McClellan to hold an emergency conference call with the board the day after he received its letter. A CMS spokesman declined to divulge details from the call or to say whether the agency would consider canceling the program, but Dr. Hetsko said the exchange had opened the door to much-needed further dialogue with CMS on the issue.

Taking a stand

Praise from AMA delegates for the board's action soon turned into a discussion about the need to hold the line against quality reporting and pay-for-performance programs that fail to meet AMA principles, whether the proposals come from Congress or the White House.

Some doctors worried that the AMA-crafted guidelines and principles are being outright ignored by policy-makers and need to be pushed harder in Washington.

"I haven't seen any evidence that our guidelines have been quoted by CMS or anybody else. I think they were an exercise in futility," said Joseph Bailey, MD, a Georgia delegate and rheumatologist. "The only effort that we're going to achieve that will be of value to us is when we get [Congress] to tell CMS to stop doing what it's doing to us."

Tensions mounted when AMA Trustee John H. Armstrong, MD, took issue with the tone of a proposed resolution directing the Association to "strongly oppose any pay-for-performance programs or pilot PFP programs that are not fully in compliance with AMA principles and guidelines." Dr. Armstrong's warning that such an inflexible stance could backfire on the group while it lobbies for Medicare payment increases prompted several accusations that the trustees were in danger of compromising on pay-for-performance in their quest to turn next year's 4.4% reimbursement cut into a 1% or higher increase.

"You don't negotiate your principles," said Carl Lentz, MD, a plastic surgeon and delegate from Florida. "They can't be bartered off for a 5% difference this year, or the same thing will happen next year."

Some delegates went so far as to suggest that physicians might need to swallow a Medicare pay cut in the short term to hold off a long-term pay-for-performance model that would be much worse for patient care.

"If we compromise our principles in favor of political expediency over a 5% difference in payment, we will have sold ourselves and our patients down the road," said Craig Backs, MD, president of the Illinois State Medical Society. "And that's not acceptable."

A "masterful" compromise

Dr. Armstrong sought to convince delegates that the AMA, while fighting for payment reform, still will vigorously oppose any harmful pay-for-performance plan.

"We have not given up in any way, shape or form in fighting the battle that leads to the end of the war for a sustained Medicare physician payment formula that meets practice costs," he said. "We are not continuing to take it, and I can provide the reassurance that on pay-for-performance or any other matter, we do not compromise our principles."

Delegates ultimately approved what Dr. Armstrong termed a "masterful" consensus measure incorporating three competing resolutions on the issue.

The final version removed the contentious references to strong opposition and total compliance with AMA principles and trimmed down specific negative references to a Medicare value-based purchasing plan recently approved by the Senate.

Delegates also adopted language instructing the AMA to launch a media and public information campaign designed to teach others about the risks of embracing pay-for-performance.

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Patients still come first, CEJA opinion says

Dallas -- Physicians who participate in pay-for-performance programs should ensure that the plans do not interfere with their primary responsibility to patients, according to a Council on Ethical and Judicial Affairs opinion the AMA House of Delegates adopted at its Interim Meeting earlier this month.

"When physicians participate in pay-for-performance programs, they must continue to keep patients first and foremost," said AMA Trustee Rebecca J. Patchin, MD, a Riverside, Calif., pain medicine specialist. "They should participate only when those programs are in their patients' best interest."

CEJA member Regina M. Benjamin, MD, said "pay-for-performance programs may benefit patients by improving quality," but that physicians must be careful to "avoid bias and avoid disadvantages to vulnerable populations" such as sicker patients, the uninsured or underinsured, and patients with limited English proficiency or poor health literacy.

Some delegates said too much of the evidence used in formulating clinical guidelines and performance measures is tainted by financial conflicts of interest.

"What we have here is a house of cards," said Arthur Gale, MD, a St. Louis internist. "The guidelines themselves can be based on rather flimsy evidence."

According to the CEJA opinion, physicians should make sure that pay-for-performance programs:

  • Allow doctors to access and evaluate the evidence upon which the program is based.
  • Adjust measures by risk and caseload mix to avoid discouraging doctors from treating high-risk patients.
  • Primarily intend to promote quality and patient safety, not simply cut costs.

If physicians believe a pay-for-performance program compromises their ability to care for patients, the CEJA opinion says doctors should refuse to participate in it.

--Kevin O'Reilly

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