Quality Improvement Pay-for-Performance Medicare Reimbursement

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Quality ImprovementPay-for-PerformanceMedicare
Reimbursement
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Why is Quality an Issue?

• Recognized gaps in quality of care
• High cost does not equal better quality
• Recognition that delayed access, underuse, misuse
  and overuse all contribute to higher health care
  costs and health disparities

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Value-Based Purchasing (VBP)

• Requires physicians to demonstrate value by
  reporting their performance based on quality,
  efficiency and patient experience measures
• Ties elements of reimbursement to physicians
  willingness to be held accountable based on such
  measures, and to report to the public on the
  results

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Where Did VBP Come From?

• Payers, pushed by purchasers, initially led the
  movement pressure to reduce costs
• Introduced performance, efficiency measures as a
  condition of contracts
• Created pay-for-performance programs
• Disclosed physician-specific performance data to
  inform consumers and generate evidence-based
  benefit design concepts

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ACP Influencing the Quality Movement

• Policy and advocacy
• Participating in multi-stakeholder organizations
  and coalitions
• Designing, contributing to demonstration projects
  and studies
• Developing processes to select and endorse
  measures
• Activities guided by policy, governance

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ACP Policy Guides Efforts

• Use of Performance Measures to Improve Physician
  Quality of Care (April 2004)
• Patient-Centered, Physician-Guided Care for the
  Chronically Ill (Oct. 2004)
• Updated Performance Measurement paper under
  development

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Key Performance Measures Criteria

• Evidence-based, broadly accepted, relevant to
  physicians, purchasers, patients
• Measurable attributes should be transparent and
  under a physician's control
• Data collection methodology should be feasible,
  accurate, reliable and practical
• Information technology should minimize the burden
  of data collection

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Translating Policy into Advocacy

• Reform dysfunctional payment policies to support
  quality improvement
• Alternatives needed for episodic,
  fee-for-service methods
• Effective care management should be rewarded
• Patients with chronic diseases should have a
  medical home, supported by management fee
• ACP supports interoperable electronic health
  records to support quality improvement

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• So ACP has policy.
• How, specifically, is this being used to support
  members?

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The Ambulatory Care Quality Alliance (AQA)

• Co-conveners ACP, AHIP, AAFP and AHRQ
• Includes all major stakeholders (medical
  societies and boards, government, large
  employers, consumers, health plans)
• Uniform set of starter measures endorsed for
  ambulatory care
• Measures meet ACP criteria

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Advantages of the AQA Process

• Reduces conflicting, duplicative measures
• Ensures scientific validity
• Limits administrative burden
• Gives ACP the opportunity to influence future
  measures, guidelines on reporting, and the use
  of data collected

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ACP Involved in Demonstration Projects

• Chronic Care Improvement Pilot
• Medicare Doctors Office Quality Information
  Technology (DOQ-IT) pilot program
• Working with QIOs in Eighth Scope of Work
• Closing the Gap Partnering for Change
  (AHRQ-funded grant)

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Influencing Health Information Technology

• Certification Commission for Health Information
  Technology (CCHIT)
• Functionality
• Interoperability
• Security

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Influencing CMS Legislation

• Advising Congressional staff, CMS, and other key
  policy makers
• Halt Medicare fee cuts
• Provide funding for HIT adoption
• Phased-in approach to P4P
• Positive fee updates for all physicians
• Patient safeguards

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The Sustainable Growth Rate (SGR)

• Unless Congress acts, Medicare payments will be
  cut by 4.3 in 2006 and 26 over 5 years
• Typical internist will lose 46,000 over 5 years
• SGR cuts relief will be costly 32 billion for
  2 years of positive updates 180 billion for a
  permanent fix
• Congress is unwilling to spend the money to halt
  the SGR cuts without creating an initial P4P
  framework

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Legislative Framework

• Endorsed by 70 physician organizations
• Measures selected by physician organizations
• Phased-in approach to P4P
• Risk adjustments
• Positive updates for all physicians while
  phasing-in additional payments for those who
  participate in P4P programs

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The Legislative Impact

• Key bills incorporate parts of ACPs framework
• Medicare Value-Based Purchasing for Physicians
  Services Act of 2005 introduced by Rep. Johnson
  (R-Conn.)
• Medicare Value-Based Purchasing Act of 2005
  introduced by Senators Grassley (R-Iowa) and
  Baucus (D-Mont.)

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Johnson (House) Bill

• Incorporates many ACP recommendations
• Repeals the SGR recognizes that SGR cuts are
  incompatible with quality improvement
• Recommends evidence-based measures developed by
  the medical profession
• Safeguards against de-selection of high-risk
  patients
• All physicians receive positive updates
• Physicians who demonstrate quality improvement
  qualify for higher payments

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Grassley-Baucus (Senate) Bill

• Measures criteria and selection process are
  largely in accord with ACP policies
• Areas of concern include
• Funding for the program and the impact of
  pending Medicare payment cuts
• Timetable for phasing-in quality measures
• Linking payments to comparative statistical
  measures that are not yet fully developed

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Current situation - November 2005

• Senate reconciliation package includes modest
  relief from SGR cuts
• Replaces 4.4 cut in 2006 with a 1 increase a
  5.4 improvement
• ACP supports 1 update as a first step, but is
  concerned that this is still below inflation and
  that payments will revert to the SGR in 2007
• Beginning in 2007, physicians will be asked to
  voluntarily report quality data and those that
  dont may incur additional reductions

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Current situation - November 2005

• House reconciliation package may not accept the
  1 increase in the Senate package
• Our immediate objective is to halt the SGR cuts,
  but ACPs goal is to redirect the debate to
  fundamentally reforming health care delivery,
  financing and reimbursement

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What Can You Do?

• Be an active participant
• Share your concerns, ideas and suggestions
• Volunteer for demonstration projects
• Become a Key Contact for the ACP Legislative
  Action Center
• Speak to your congressional representatives

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For More Information

• Read the latest news in ACP Observer
• Sign-up to receive ACP ObserverWeekly
• View ACPs quality improvement Web site
  www.acponline.org/quality
• Sign-up to get ACP legislative alerts
  www.acponline.org/hpp/advocacy