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Dr. John Gordon Harold, ACC president
Harold

Doc associations wary of linking pay, quality measures


By Andis Robeznieks
Posted: April 25, 2013 - 12:00 pm ET
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U.S. House of Representatives committee chairmen asked for guidance on replacing the sustainable growth-rate Medicare physician payment formula, and healthcare associations were happy to comply.

And, while there was general support for the still-developing plan, the responses reflected the concerns of each responding association's constituency—particularly their financial concerns.

The Alliance of Specialty Medicine, American Academy of Family Physicians, American College of Cardiology, American Medical Group Association and the Medical Group Management Association responded to a request for comment from the chairmen of the House Energy and Commerce and Ways and Means Committees—along with their respective health subcommittees—on a second iteration of a plan to replace the SGR with a system featuring predictable payment rates and rewards for quality and efficiency.

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The movement to replace the SGR gained steam when the Congressional Budget Office issued a revised $138 billion estimate on replacing the troubled formula that was 40% lower than the previous estimate of $245 billion. If Congress fails to act, the SGR calls for cutting physician Medicare pay by 24.4% on Jan. 1.

“We are strongly supportive of the direction taken by the committees in this document,” Dr. John Gordon Harold, president of the American College of Cardiology (PDF), wrote in his letter. “We support a careful and iterative movement towards a payment system that better recognizes the value of care. We support a plan that recognizes that the practice of medicine is extraordinarily diverse and requires some customization to measure performance and outcomes. We support a plan that promotes continued incentives to improve for both the highest and lowest level performers.”

Harold wrote that value-based payment updates should reflect the savings Medicare has seen as a result of improved quality and efficiency, but balked at the chairmen's call to rely on measures that have received the endorsement of groups such as the National Quality Forum. According to Harold, the NQF's broad consensus-building process may not be as applicable as measures developed specifically for cardiology by the ACC or other cardiology organizations.

The Alliance of Specialty Medicine (PDF), a coalition of 13 specialty societies, called for physician-driven quality measurement, flexibility, gradual implementation, positive incentives, minimal reporting burden, a greater emphasis on quality over cost, timely feedback, a fair appeals process and other related concerns. It also suggested that the NQF was a fine organization, but thought that specialty societies might have more expertise and agility to develop quality measures—though perhaps not the resources.

“While evidence-based approaches to measurement are preferred, current standards, such as those used by the National Quality Forum, are often too resource intensive to justify investment, too lengthy to allow for timely implementation, and too rigorous to accommodate the testing of more innovative approaches to quality improvement—such as reporting to a clinical data registry—which may provide the very data needed to fill current gaps in the evidence,” according to the alliance's letter. “Most, if not all, specialty societies regularly provide input into the current measure development process. However, few have actually taken the lead on measure development, citing cost and lack of data to support validated measurement as the primary deterrents.”

Speaking from the primary-care side, the AAFP's letter began with a compliment of the committee's work—especially for the speed at which it's progressing. But then it noted concerns about the measures proposed for calculating value-based payments.

“The current version of the committees' proposal seems to assume that performance measures alone lead to higher quality healthcare,” Dr. Glen Stream, AAFP chairman, wrote in his letter. “It is our experience that performance measures can be used to improve targeted areas of healthcare delivery, but quality improvement is more complicated and more individual than can be reflected in performance measures alone.”

Evaluation and management services accounted for 45% of Medicare-funded services in 2011, and there are efforts to increase reimbursements for these services provided by primary-care physicians as they have lagged behind payments for procedures performed by specialists.

In his letter, Stream calls for “permanently increasing payment for primary-care services by adoption of separate primary-care evaluation and management codes with higher values that reflect the complexity and intensity of the services provided by primary care physicians and the patients served.”

In their request for comment, GOP congressmen Fred Upton and Dave Camp, both of Michigan; Joe Pitts of Pennsylvania; and Kevin Brady of Texas asked what should be done about specialties that have not established sufficient quality measures.

In his letter, Stream was not sympathetic.

“AAFP believes these specialties have had ample time and opportunity to develop measures and no special consideration should be given,” he wrote. “Congress should direct CMS to work with specialty certification boards and specialty societies to establish and maintain a set of measures which support national health priorities.”

In its letter, the MGMA-ACMPE wrote that “practices can best improve quality in a non-punitive environment,” and it added that there must be flexibility for practices to adopt payment arrangements that best suit their composition and capabilities, including continuing with fee for service.

“Rewarding quality and cost effectiveness through a 'tournament style' approach to foster competition within physician specialties will only lead to unintended consequences such as discouraging sharing of clinical best practices,” Dr. Susan Turney, MGMA-ACMPE president and CEO (PDF), wrote in the letter. “We reiterate our position that in order to find a solution to the current broken payment system, we also need to break down the silos between separate payment systems for different sectors of Medicare.”

Turney also expressed concern about the Congressmen's proposal to address nonphysician providers separately, and wrote that nonphysicians working within the scope of their practice should be held to the same standards as doctors for the care they provide.

At the AMGA's annual conference, held last month in Orlando, Fla., the organization's government advocacy team stated that a focus of their 2013 legislative efforts will be working to insert the AMGA definition of a “high-performing system” into healthcare bills. True to their word, this definition is included in their letter.

In his letter, Donald Fisher, AMGA president and CEO, cited the House leaders' goal to “reward providers for delivery high quality, efficient care,” but he added that “there is often confusion about what constitutes a health system and why these systems should be incentivized.”

So Fisher spelled it out, and he wrote that such systems offer services efficiently across an organized continuum of care, while measuring and improving quality, coordinating care and using information technology and evidence-based medicine. Compensation should be geared toward promoting these practices, and “provider entities” should share financial, regulatory and quality accountability.

“We believe that Congress can use the attributes outlined above for successfully managing healthcare costs, improving the overall patient experience, and improving the health of patient populations,” Fisher wrote.

Follow Andis Robeznieks on Twitter: @MHARobeznieks


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