AMA leads project to develop quality measures by year's end

AMA leaders say the agreement with lawmakers averted a hasty shift to Medicare pay-for-performance. Some specialty societies are critical of the initiative.

By David Glendinning — Posted March 13, 2006

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The American Medical Association has assured Congress that physicians are ready to put the final pieces in place for a workable voluntary Medicare quality reporting system by the end of this year. But some medical specialty groups, saying that this road inevitably leads to pay-for-performance for doctors, worry that the AMA has promised more than physicians can deliver.

At the heart of the dispute is a joint House-Senate working agreement signed in December 2005 by AMA Board Chair Duane M. Cady, MD; Senate Finance Committee Chair Charles Grassley (R, Iowa); House Ways and Means Committee Chair Bill Thomas (R, Calif.); and House Energy and Commerce health subcommittee Chair Nathan Deal (R, Ga.).

The document states that physician groups will have developed roughly 140 quality-of-care measures by the end of 2006 and that each doctor can start voluntarily informing the government how well he or she does on at least three to five of them, starting in 2007. Physicians who do so should receive extra Medicare compensation next year to cover the costs of collecting the data, the plan states.

The Association said that this timetable is well within the physician community's grasp. The Physician Consortium for Performance Improvement already has developed 90 such measures and is well on the way to producing dozens more, said Nancy H. Nielsen, MD, PhD, speaker of the AMA House of Delegates. The AMA-convened consortium brings together representatives from more than 70 national specialty societies and state medical societies with government representatives in an effort to boost the quality of medical care.

"This can be slow work, but it does not have to be," Dr. Nielsen said. Consortium members developing dedicated quality measures within their areas of clinical expertise are already working at full tilt to find the best ways to assess medical care, she said.

Too much too soon?

But at least 10 medical specialty societies disputed the assessment that the work could be completed on time and expressed dismay that the AMA had made a commitment with Congress to follow what they consider an overly ambitious schedule. The groups, including the American College of Emergency Physicians, the American Academy of Orthopaedic Surgeons and the American College of Obstetricians and Gynecologists, said that not all of the physician community would be able to keep up with such a fast pace.

"While we have already been working to ready our organizations to prepare for pay-for-performance, we are concerned that this agreement binds organizations to timelines and processes that may not be able to be accomplished by all medical specialties," the groups said in a Jan. 31 letter to lawmakers after details of the AMA working agreement came to light.

Some physician specialties, for instance, are much further along than others in developing workable quality measures, said Stuart L. Weinstein, MD, president of the American Academy of Orthopaedic Surgeons. Given the need to rigorously field-test and risk-adjust the measures after they have been developed, an additional 50 entries by the end of the year becomes much more difficult -- if not impossible -- to attain, he said.

The AMA points out that the congressional agreement concerns voluntary quality reporting, not physician pay-for-performance, an issue that has generated significant controversy in the medical community. Implementing a system under which Medicare pays more to doctors who provide higher quality care will require future legislation from Congress, Dr. Cady wrote in a Feb. 23 letter responding to specialty society criticism of the deal.

Concern over pay-for-performance

But many physicians are worried that lawmakers won't be satisfied with voluntary reporting alone and will soon convert the program into a full-fledged pay-for-performance system, said Frederick C. Blum, MD, the American College of Emergency Physicians' president. Once Medicare quality measures are in play, Congress can simply legislate payment changes that effectively remove the voluntary designation by reducing payments to nonparticipants and low performers, he said.

Citing this perception that the issues of quality measurement and physician payments are inextricably linked, the physician specialty societies said they were disappointed that the AMA was not able to secure a commitment from lawmakers to fix the Medicare payment formula. The formula has doctors facing tens of billions of dollars in cuts over the next decade.

Dr. Cady, in his letter, countered that the physician community did get something significant in return for the AMA signing the working agreement. At the time, a Senate-passed Medicare pay-for-performance program opposed by the Association and myriad specialty groups was still in play during lawmakers' final negotiations on a deficit reduction package.

"The three key committee chairs were intent on securing some commitment that physicians would work on a voluntary reporting program if the Senate provision was not included in the final conference agreement," he wrote.

The commitment also was necessary to quell congressional concerns that physicians were not serious about reporting data to the government in the name of improving quality of care, Dr. Cady wrote. This perceived misunderstanding arose late last year when the AMA and other doctor groups came out in strong opposition to the Centers for Medicare & Medicaid Services' voluntary quality reporting system, he said, a program that CMS has since significantly altered in response to the criticism.

"On Capitol Hill, however, these views were interpreted as opposition by the AMA to quality reporting," Dr. Cady wrote. The Association decided that signing the agreement was a show of good faith from physicians that would help dispel any such doubts from lawmakers.

The specialty societies also expressed their discomfort with the fact that the AMA negotiated the confidential agreement on behalf of "physician groups" without any specialty representatives present, but Dr. Blum said that the organizations understand the pressures that the Association was under last December.

Dr. Cady stated that the lawmakers asked the AMA to keep a lid on the agreement, which took place amid tense 11th-hour negotiations on the deficit reduction bill.

The Association also said that while the agreement itself was confidential, the commitments outlined in the document were not. In a set of public letters sent to lawmakers and Bush administration officials in December 2005 that used nearly identical language, the AMA outlined the consortium's plan to develop approximately 140 quality measures this year for voluntary reporting starting in 2007.

Despite the specialty societies' concerns over how the issues of voluntary quality reporting, physician reimbursement and pay-for-performance played out last year, the physician groups involved cited the need for doctors to work together toward common goals.

"We'll all get past this," Dr. Blum said.

Dr. Cady stated the price physicians would pay for not doing so could be steeper than they would care to accept.

"If organized medicine does not work together on these challenging issues, government officials and health plans will fill the void," he wrote.

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Agreement details

Here is the text of the joint House-Senate working agreement with the American Medical Association on voluntary quality reporting:

  • In 2006, physician groups will work with the Centers for Medicare & Medicaid Services to reach agreement on a starter set of evidence-based quality measures for a broad group of specialties for review by a consensus-building process.
  • By the end of 2006, physician groups will have developed ... approximately 140 physician performance measures covering 34 clinical areas.
  • In 2006, physician groups will work with CMS to develop the most accurate and efficient method for physicians to report quality data to CMS.
  • During 2006, physician groups will [work] with CMS, the House Committee on Ways and Means, the House Committee on Energy and Commerce, and the Senate Committee on Finance to implement additional reforms to address payment and quality objectives.
  • In 2007, physicians would report voluntarily to CMS on at least three to five quality measures per physician. Physicians [who] report measures should receive an additional quality update to offset administrative costs.
  • By the end of 2007, physician groups will have developed performance measures to cover a majority of Medicare spending for physician services.

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Private sector initiatives

As Congress and the Bush administration consider how to incorporate voluntary quality reporting and eventually physician pay-for-performance into Medicare, insurers and employers are increasingly putting these concepts into practice in the private sector.

A recent issue brief from the nonpartisan Alliance for Health Reform reported that more than 100 health care pay-for-performance initiatives are up and running in the United States. Architects of the plans continue to learn lessons on the ground as they offer to pay physicians and other medical professionals based on their quality of care.

Some programs are reporting successes as demonstrated by the number of doctors they are enticing to participate. For instance, a California-based coalition of health plans, physician groups and others known as the Integrated Healthcare Assn. has paid out more than $60 million to tens of thousands of participating physicians who have exceeded quality benchmarks, the alliance reported.

"There has to be a trust, a feeling that it's done in the right way," said Ron Bangasser, MD, one of the planners of the IHA program. "You're going to get huge pushback from physicians if they don't feel that they're involved."

Not every pay-for-performance effort in the private sector has met with such success. The insurer UnitedHealthcare re-engineered its pay-for-performance product after the Performance Provider program that debuted a year ago met with strong protests from doctors for its primary focus on squeezing costs. United's new Practice Rewards program, operating in the Cleveland and Chicago areas, stresses health quality over cost savings, according to the Medical Group Management Assn.

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