Psychiatr News December 2, 2005
Volume 40, Number 23, page 1
© 2005 American Psychiatric Association
AMA Delegates Bash New Medicare Reporting System
Mark Moran
APA has joined the AMA in cautioning that the Bush administration is
moving too quickly toward pay-for-performance programs and has criticized
depression measures in a voluntary reporting system.
Enough is enough! That was the refrain from physicians at the AMA House of
Delegates meeting who reacted with anger and frustration to a new voluntary
data reporting program floated by the federal Centers for Medicare and
Medicaid Services (CMS) just days before the AMA meeting last month in
Dallas.
What delegates and state and specialty societies were responding to with
uncommon rancor was the Physician Voluntary Reporting Program (PVRP),
announced by CMS on October 28 and set to begin in January 2006. The PVRP will
allow physicians who choose to participate to submit quality information on
Medicare claims and receive feedback on their performance as early as summer
2006.
The program is voluntary and is not linked to Medicare reimbursement, but
it is widely regarded as a preliminary move toward "pay for
performance"—the concept of paying physicians for adhering to
quality measures, which CMS is piloting on a small scale in 2006.
That move toward pay for performance (or P4P) was itself the object of
scorn at last month's AMA meeting (see
page 8).
According to CMS, the administration will begin to collect information
through use of so-called "G-codes," a set of codes used to
identify professional health care procedures and services that would otherwise
be coded in CPT-4 but for which there are no CPT-4 codes,
and that are reported on the preexisting physician claim form. These codes
will supplement the claims data that doctors currently submit to CMS with
clinical data.
These clinical data will then be used to measure the quality of services to
Medicare patients. CMS anticipates that these G-codes will serve as an interim
step until the electronic submission of data through electronic health records
replaces this process, and CMS expects to collaborate with participating
physicians to develop such electronic data-submission methods.
Although some of the measures selected by CMS were originally drawn up by a
physicians' consortium convened by the AMA, many originated from the National
Committee on Quality Assurance and were designed for use by national health
plans rather than individual physicians using physician-acquired data. CMS
added a number of other measures and developed the G-codes to adapt them to
the Medicare claims system.
AMA delegates said the reporting program will likely add uncompensated
administrative burdens. And in what they regarded as a particularly malevolent
twist, the program was announced the same day as a 4.4 percent reduction in
overall Medicare payments for 2006.
So at last month's meeting AMA delegates—criticizing both the content
of the measures and the way in which the program was rolled out—roiled
with hostility toward a government that appears unwilling to fix a flawed
payment system but at the same determined to rush pell-mell into an untested
pay-for-performance system.
"Enough is enough is enough," said Chester Danehower, M.D., of
Idaho, expressing the clear sense of the house.
Richard Warner, M.D., a psychiatrist from Kansas, registered cynicism about
the move toward P4P generally. "These pay-for-performance programs
appear to be about judging us on quality," he said. "But that is
only an appearance. What it is really about is establishing the primacy of
third-party payers in deciding how medicine should be shaped."
And Michael Sexton, M.D., a member of the AMA's Advisory Committee on Group
Practice Physicians, said the group had been working diligently to help
develop workable measures of physician performance but was sorely disappointed
in the government's PVRP.
"We were very sad to see the way this rule came out," he said.
"We strongly urge the CMS to immediately withdraw this rule. It will do
more damage to what we are trying to accomplish."
With near unanimity the house approved a resolution calling on CMS to
withdraw the PVRP. It followed a letter sent to CMS Administrator Mark
McClellan, M.D., Ph.D., by the AMA Board of Trustees just days after the
program was announced.
"The excessive administrative requirements that this program will
impose on physicians could doom this initiative and negate any intended
quality improvements," the trustees said. "We strongly urge you to
rescind this project. In addition, we recommend a fresh start on future CMS
quality activities starting with a meeting between you and physician leaders
that leads to meaningful dialogue."
The 36-measures in the PVRP include two on use of antidepressants in
treating depression during the acute and continuous treatment phases. Along
with AMA, APA has repeatedly cautioned that the administration is moving too
quickly toward P4P without testing the initiatives.
More recently, APA has communicated its concerns about the two PVRP
measures—among them, that they seem to be biased toward treatment with
medication over psychotherapy, even when that may not be indicated for a
patient.
For instance, APA suggests that other measures might be more helpful to
ensure appropriate treatment, such as whether a measure of severity of
depression, through use of a standardized instrument such as the PHQ-9 or Beck
Depression Inventory, is obtained.
"APA shares the AMA's concern about the method and manner in which
CMS is proceeding with performance-measure reporting," Nicholas Meyers,
director of APA's Department of Government Relations, told Psychiatric
News. "While the PVRP is voluntary and not tied to Medicare
payments at this time, it amounts to a field test of what will eventually be a
reporting system tied to performance payment and adds to the time physicians
have to devote to paperwork.
"Worse, precisely at the point CMS is announcing a new
performance-measure reporting system, it is also announcing a [Medicare] pay
cut," Meyers said. "APA has already identified several serious
technical problems with the CMS manual instruction on the two
depression-related measures." The AMA house resolution was strongly
supported by the Section Council on Psychiatry. "This elaborate
reporting plan is poorly thought out and did not involve the appropriate
stakeholders," said section council chair John McIntyre, M.D.
"Moreover, its impact on the quality of care, which is what is intended,
is very dubious."
Information about the PVRP and G-codes for the 36 performance
measures is posted at
<www.cms.hhs.gov/providers/p4p/>.
Related Article:
-
Pay for Performance Raises Anxiety Level at AMA
- Mark Moran
Psychiatr News 2005 40: 8.
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