Medicare Pay for Performance
— An Emerging Voluntary Program? And, What
About SGR Reform?
Ronald Szabat, J.D., LL.M., Director
Governmental Affairs and General Counsel
ake no mistake about it, the human, physical and
real property tragedies of hurricanes Katrina and
Rita have left America with a heightened appreciation
for the classic economic trade-offs between “guns
and butter.” While there are those on the
national scene who profess that we can still spend
freely on both axes without consequence, this fall’s
congressional effort to restrain so-called “unnecessary”
federal spending and control the deficit tells us
something different. For now, the collective majority
do not believe that we can be all things to all
people all the time with dollars to match. Ironically,
and harshly, the good that comes from this realization
has had its roots in the terrible destruction that
twin natural disasters have so unfairly inflicted
on the innocent.
What will this mean for the very programs that cause
anesthesiologists and other physicians to interface
on a daily basis with a federal government already
unwilling to pay market prices for medical care
to the nation’s elderly and disabled? As we
say here in Washington, the answer is “as
clear as the Potomac.” (And for those who
have not seen it, the Potomac River has a rich daily
flow of mud, silt and ample algae.) Recent controllable
events in and around the District of Columbia provide
clues to what may be ahead, however.
For example, just before the start of October, the
House Ways and Means Health Subcommittee held its
fourth hearing this year on Medicare pay for performance,
or “P4P.” This new acronym is the largely
untested notion that clinical quality determinants
can eventually be developed and extended across
the vast Medicare program to improve quality of
care and rationalize payments to physicians and
others involved in providing medical care.
The focus of this hearing, on which ASA submitted
testimony, see <www.ASAhq.org/news/05OctASAStmttoWaysandMeans.pdf>,
was H.R. 3617, the “Medicare Value-Based Purchasing
for Physicians’ Services Act of 2005,”
introduced by Chairwoman Nancy Johnson (R-CT). As
discussed in previous columns, this bill would tie
a portion of future Medicare physician payments
to reporting and performance on quality measures.
Of major significance, Mrs. Johnson’s legislation
would replace the current Sustainable Growth Rate
(SGR) formula for computing Medicare physician fee
updates with one that is based on the Medicare Economic
Index (MEI), a point on which organized medicine
firmly agrees.
In terms of predicting the future, Members of Congress
on both sides of the aisle have repeatedly said
that the SGR is flawed, though they have disagreed
over how to fix it and how to begin paying physicians
and other providers for quality. As November drags
on, Congress is nearing the time when this issue
must be decided to avert automatic cuts in Medicare
reimbursement to all Medicare physicians in 2006.
At the same time, the Centers for Medicare &
Medicaid Services (CMS) is moving rapidly toward
a massive voluntary demonstration project that would
allow it to collect data through the existing Medicare
claims submission process on a “starter set”
of physician-determined quality indicators. The
problem of how payment would or would not be related
to these indicators remains to be determined.
This much is clear, however. ASA, as the leading
national medical specialty society speaking for
anesthesiology, critical care and pain medicine,
has submitted to CMS and had tentatively approved
three important clinical measures that eventually
may be found in a voluntary Medicare demonstration
project. The first is on maintaining immediate postoperative
normothermia for patients undergoing general anesthesia
for greater than 60 minutes. The second is on antibiotic
prophylaxis within one hour of surgery prior to
incision time (two hours for vancomycin). And the
third is that chronic pain management patients have
a documented comprehensive history and physical
consistent with guidelines.
All of these are small first steps, but important
ones, too, that can and will show whether or not
such data-gathering works before any firm links
are made to Medicare payment or not. This is the
vision behind Mrs. Johnson’s bill, and ASA
is committed to working toward full and fair SGR
resolution as well as any broader implementation
of the P4P constructs, if warranted.
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