Medicare's low-quality program

Medicare's soon-to-be-launched Physician Voluntary Reporting Program is expected to be the first step in creating a systemwide pay-for-performance program focused on quality improvement. But it's fitting that the word quality isn't in the name, because it appears the program's ability to promote better care is highly questionable.

Though Medicare as yet has no broad pay-for-performance program, the PVRP allows physicians who choose to participate to submit quality information on Medicare claims and receive feedback on their performances.

Physician participation in PVRP is not linked to Medicare reimbursement. The program begins on Jan. 1, 2006, and expects to start reporting performance results to physicians by that summer.

The problem is, Medicare's program falls short on credible quality standards and is long on onerous administrative burdens.

On Nov. 3, the American Medical Association sent a letter to Centers for Medicare & Medicaid Services Administrator Mark McClellan, MD, PhD, expressing its "strong objection" to the PVRP. The letter, signed by the AMA Board of Trustees, outlined several major problems with the program.

It details the ways in which CMS, despite the AMA engaging it in a variety of settings on how to most accurately measure performance, used little of that input in constructing the PVRP. "In the PVRP, CMS has bypassed a significant body of collaborative work in favor of its own reporting program," the board wrote in its letter.

The PVRP, rather than using a uniform code, is a jumble of temporary "G-codes" (codes CMS says will be used until electronic submission of clinical data replaces the need for them), hospital-level measures rewritten by CMS, and measures developed by the Rand Corp. and others.

As an example of the lack of clarity this creates, the board's letter states that a physician could contemplate nearly 40 potential G-codes and about a dozen performance measures when treating a 70-year-old female Medicare patient with osteoporosis, diabetes and heart disease.

If the care is in the inpatient setting, physicians face the problem, because of the hospital-level measures, of documenting the quality of care attributable directly to the individual doctors, rather than to hospital staff carrying out orders.

The letter continues to say that few practice management and electronic health records systems are ready for the PVRP, meaning that physicians would have to contract with their software vendors for upgrades, which would add "significant new costs to their overhead."

All of this comes at a time that doctors are being reminded of what a bleak financial future Medicare has in mind for them -- a 26% pay cut over six years unless the system is reformed. (At press time, lawmakers were set to review a 1% one-year-only increase for next year.)

The AMA House of Delegates agreed with the board, voting during its Nov. 5-8 Interim Meeting to continue to oppose the PVRP in its current form. Delegates also committed the Association to work with other Federation organizations to express that opposition and offer assistance to rectify the program's deficiencies.

The house, during this year's June Annual Meeting, approved principles and guidelines for all pay-for-performance programs. The principles, which the guidelines expand upon in detail, specify ensuring quality of care, fostering the patient-physician relationship, offering voluntary physician participation, using accurate data and fair reporting, and providing fair and equitable program incentives. (Delegates in November also approved ethical standards stating that physicians should participate in, or help design, only the pay-for-performance programs that are consistent with these principles and guidelines.)

Physicians want to participate in ways to improve the quality of care and were doing so long before Medicare arrived on the scene. But building a plan around questionable standards, unnecessary costs and administrative burdens is not the way to move forward.

It's time for Medicare to rethink its program and what will come from it.