The American Medical Association, struggling with concerns about the impact of pay-for-performance programs on quality of care and physicians' finances, approved a strict policy asking such plans to adhere to a long list of guidelines, including mandatory pilot-testing.
The policy was approved overwhelmingly by the AMA's 534-member House of Delegates at its annual meeting last week in Chicago, but the tough stance could hinder the nation's largest doctors' group in negotiations about pay-for-performance plans and future Medicare payment rates.
The reason: Lawmakers in Washington expect to tie increased Medicare reimbursement to the medical profession's acceptance of federally sponsored pay-for-performance plans, observers said.
"I think the AMA runs the risk of being perceived as saying, 'It's my way or the highway,' " said Mary Frank, M.D., president of the American Academy of Family Physicians. "There's no reason to put up these kinds of obstacles."
Robert Doherty, senior vice president of the American College of Physicians, said, "This is going to make it very difficult for the AMA to engage constructively in influencing what comes out of Medicare. I think it's highly unlikely that legislation (on pay-for-performance plans) will meet all of the AMA's criteria."
Some delegates agreed with that assessment, saying the AMA would be hampered on Capitol Hill if it insists all pay-for-performance plans not only be pilot-tested but also meet every condition outlined by the doctors' group.
The guidelines run nearly four single-spaced pages long and include about 50 detailed conditions in five general categories, covering such areas as the patient-physician relationship, physician participation and incentives.
Among other criteria, pay-for-performance programs would have to:
James Bean, a delegate from Lexington, Ky., said the AMA must be steadfast in its principles and guidelines, even at the risk of alienating some lawmakers.
"We don't -- and we shouldn't -- negotiate out of fear," Bean said. "And we shouldn't compromise our beliefs."
John Armstrong, M.D., secretary of the AMA's board of trustees, warned delegates before the vote that the policy could "tie our hands" in future negotiations with government, insurance companies and business.
But he downplayed those concerns afterward, saying it made sense for the AMA to stick by its principles on an issue affecting quality of care.
He also said the principles allow for some leeway in negotiations. "Our guidelines provide some nuance," Armstrong said. "That's how you start negotiations -- you start on principles."
While the AMA carved out a strong position on pay-for-performance, other medical groups were signaling their intent to compromise with Congress to avert deep cuts in Medicare payments for physicians.
A 4.3% reduction is scheduled to take effect Jan. 1, and the long-term forecast calls for a 26% reduction through 2011.
In a letter to Senate Majority Leader Bill Frist, M.D., four of the largest primary-care organizations pledged "support and assistance" in developing legislation that would increase Medicare payments while phasing in pay-for-performance plans over several years.
The groups -- the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American College of Obstetricians and Gynecologists -- represent about 300,000 physicians.
"We're committed to making this work," Frank said.