AMA meeting: AMA toughens P4P policy, vows to oppose problematic programs

Chicago -- The American Medical Association House of Delegates last month beefed up the AMA's policy on pay-for-performance programs by giving the Association freer rein to go after initiatives harmful to patients.

After intense debate, delegates at the Annual Meeting largely reaffirmed existing AMA policy on pay-for-performance but added language stating it would "actively oppose" any program that does not meet all of the Association's principles on the issue. First adopted two years ago, the principles maintain that programs must be voluntary, ensure quality of care, foster the patient-physician relationship, establish fair and accurate performance measures, and offer positive incentives -- not penalties.

During its 2005 Annual Meeting, the house voted to oppose programs that did not meet the principles. But by reaffirming this opposition and adding the word "actively," delegates this year agreed that the gloves should come off if the Association determines that a given public or private pay-for-performance initiative is in violation, said AMA Trustee J. James Rohack, MD.

"We interpret this to say that if we find a plan is being problematic, we can work with entities to try to correct that and don't need state societies' permission to come in," he said. "Sometimes, especially when we look at insurers that cross state boundaries, we will have to take action because of the implications that may affect all physicians."

The AMA already is claiming victory in heading off at least one public program that did not make the grade. Medicare's first attempt at a voluntary reporting program -- considered by many to be a precursor to pay-for-performance -- has been abandoned. It was replaced by a six-month pilot that uses new money for bonuses and uses measures developed by physicians. Dr. Rohack said that strong physician opposition to the initial plan was instrumental in that switch.

The new AMA policy is geared not only toward opposing undesirable programs. The house also voted for the Association to join other entities in developing new quality initiatives for the exclusive benefit of patients. These programs would need to preserve access to care and be free of third-party meddling with the patient-physician relationship in order to muster approval.

Not all pay-for-performance programs have proven deleterious to patient care, Dr. Rohack said. He pointed to an Integrated Healthcare Assn. project engineered in part by the late Ronald Bangasser, MD, a California family physician and AMA delegate, as one example of an initiative that has received good marks.

Some physicians are not convinced that organized medicine can chart a clear path to positive pay-for-performance. AMA trustees and supporters on the issue had to hold back several attempts to have the Association reject the concept completely.

A number of resolutions cited recent studies showing that pay-for-performance has failed to improve patient outcomes and has even been linked to access problems. Because programs tend to redirect health care dollars and prompt some doctors to avoid seeing patients who will lower their quality scores, tying payment to performance can actually make health quality worse, several physicians said.

"Organized medicine cannot keep prescribing a medication that doesn't work, and that's what pay-for-performance is," said Peter E. Lavine, MD, an orthopedic surgeon and alternate delegate from Washington, D.C.

Some delegates proposed that the AMA try to bring about an immediate stop to all existing public and private pay-for-performance programs until it could determine whether an acceptable initiative is even possible. Otherwise, physicians would simply be standing by as payers continue to roll out programs that endanger patients and degrade quality while boosting profits for insurance companies and revenues for the government, they said.

But following a theme expressed in recent years by AMA trustees, opponents of making such an about-face on the issue warned that it would give physicians a bad name and tie their hands as they attempted to negotiate for improvements.

"Can you imagine the publicity if the AMA changes course and walks away from pay-for-performance? The press may well say that doctors are not interested in improving quality, only improving their bottom line," said Richard M. Peer, MD, a vascular surgeon and delegate from Buffalo, N.Y. "It is critical that physicians be at the table, or we will be on the table."

In the end, delegates urging a more moderate approach prevailed, but they indicated strategies might change if developing initiatives take a turn for the worse.

The new policy authorizes an annual AMA report investigating new and existing programs. The first report is due at November's Interim Meeting.