Medicare Pay for Performance
— Moving Closer to Reality
Ronald Szabat, J.D., LL.M., Director
Governmental and Legal Affairs
ongressional and Bush Administration efforts to
institute a “quality and efficiency”
system for Medicare physician reimbursement are
moving rapidly forward, with no clear commitment
yet to fix the underlying sustainable growth rate
formula problem that will lead to payment cuts on
January 1, 2006. Just before the Fourth of July
congressional recess, Senators Charles E. Grassley
(R-IA) and Max Baucus (D-MT) introduced S. 1356,
the Medicare Value Purchasing Act of 2005, which
would set in motion a conversion by 2008 to new
mandatory incentives, penalties and program requirements
under Medicare through a so-called “value-based”
purchasing program. Under the bill, preliminary
reporting by individual physicians to CMS would
begin in 2007.
In a nutshell, the bill would give sweeping authority
to the Secretary of Health and Human Services to
impose quality measures in a number of discrete
health care sectors, including those for physicians,
hospitals, skilled nursing and home health. Interestingly
and perhaps ominously, parallel requirements would
be imposed on the Medicare Advantage plans that
are scheduled to come into existence in 2006, with
no guarantee in the emerging legislative language
that any related requirements on physicians under
such “privatized” Medicare plans would
be the same as those under the traditional Medicare
program. Also troubling is the lack of guarantee
that specialty-specific measures, despite our best
efforts, would be accepted from the individual national
medical specialty societies and then implemented
by the Centers for Medicare & Medicaid Services
(CMS), as opposed to being imposed from other sources.
This possibility is especially concerning in the
largely uncharted waters of “efficiency”
measures.
While there is much in theory that is supportable
in such a bill given anesthesiolology’s tremendous
leadership role in advancing patient safety and
improving the quality of patient care, the troubling
aspects of the bill will require input from across
the medical community and from our leaders and committee
members within anesthesiology as we move through
the summer and into the early fall. Fortunately
Senators Grassley and Baucus have shown a great
willingness to work with physicians, and anesthesiology
in particular, to address our concerns. Our meetings
with them continue to be productive and fruitful,
and their leadership in advancing “quality”
is to be commended.
At the same time, organized medicine must not let
the traditional physician commitment to providing
the best possible quality care for patients be corrupted
into a hard-edged cost-containment sword by government
bureaucrats and health insurers. As written, the
bill would create a 1 percent to 2 percent withhold
pool of money, rather than new money being added
to Medicare, that then would be redistributed among
the specialties whose quality measures have been
accepted. Under the bill, payment of such “bonuses”
could be delayed for up to two years, depending
on how quickly CMS could make necessary calculations.
On the House side of Capitol Hill, a related bill
was introduced just before the August recess by
our good friend Nancy L. Johnson (R-CT), Ways and
Means Health Subcommittee Chairwoman, that seeks
to be beneficial to patients in ensuring health
care and fair to physicians by eliminating Medicare’s
onerous SGR formula. At issue in both bills will
be the designation of the appropriate public-private
entities that could help to evaluate specialty-derived
measures which CMS might implement through claims-based
data submission.
Also of interest is emerging legislation on health
information and technology (IT) that could provide
a way for Medicare and private payers to collect
data on quality indicators from medical records
in a patient de-identified manner. Along with the
above Grassley-Baucus bill, Senate Committee on
Health, Education, Labor and Pensions Chairman Michael
B. Enzi (R-WY) and Ranking Democrat Edward M. Kennedy
(D-MA) have introduced S. 1418, the “Wired
for Health Care Quality Act,” which would
require the development of standards on interoperability
and other technical measures for health IT systems
through a public-private consultative process. Full
Senate action on this measure is probable in the
coming month carefully, slowly and fairly.
With so much at stake in the world of Medicare reimbursement
and “quality,” summer is an ideal time
to weigh in with your elected federal legislators.
Your U.S. Senators and Representatives need to hear
that so-called “pay for performance”
must be implemented carefully and slowly. In your
calls and e-mails, stress anesthesiology’s
wonderful track record of improving outcomes and
promoting patient safety. Make specific reference
to the Wall
Street Journal
article of June 21, 2005, “Once
Seen as Risky, One Group of Doctors Changes Its
Ways” <webreprints.djreprints.com/1254400029287.html>.
Add that any new value-based Medicare payment scheme
must add new money to Medicare and not be administratively
burdensome. A fix for the unworkable Medicare SGR
formula also is urgently needed.
With so much at stake, your efforts are needed now
to help all of anesthesiology and medicine. Some
helpful links for contacting your legislators are
<www.house.gov>
and <www.senate.gov>.
Please help us to help you by contacting Congress
today. And, of course, please enjoy the rest of
the summer!
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