AMA Delegates Bash New Medicare 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/>.▪