April’s
Thoughts:
Creating Value for Your Patients and Your Practice
By Jesse Moss Jr., MD
As physicians, we are
increasingly frustrated by hospitals’ and payers’ demand for documentation of
the process and outcomes of the care we provide. As one of my physician friends
said recently, “When will this reporting ever end?” In the past, it was enough
that we were appropriately trained, licensed and privileged to care for our
patients. We know what is best for our patients. We have provided the very best
clinical services for our patients. Why all the fuss about care measures, and
what’s in it for the practicing physician?
Value-based
purchasing (VBP) is the concept of paying for clinical outcomes rather than just
clinical services. The concept of value-based purchasing was legislated during
the (George W.) Bush administration. The Deficit
Reduction Act of 2005 required Medicare (CMS) to develop an approach to VBP
for Medicare hospital services by 2009. The Tax
Relief and Healthcare Act of 2006 created VBP payment incentives for
hospital performance. Hospitals were initially paid a 0.4 percent bonus in 2004
for reporting specific clinical process (Core) measures. This was modified in
the Deficit Reduction Act of 2005 to a 2 percent reduction in Medicare payments
for not reporting these Core measures. In October of 2012, hospital Medicare
payments will be tied to the actual results of these Core measures: avoidance
of preventable complications and patient satisfaction scores. Progression from
payment for reporting, to cuts for not reporting, to payment based on the
actual results of care measures happened over about a nine-year period.
The Tax Relief and Healthcare Act of 2006
also created the Physician Quality Reporting System (PQRS) to pay physicians
for reporting clinical outcome measures (www.cms.gov/pqri/). Physicians are now
offered a 2 percent bonus on Medicare payments for reporting care measures. In
2015, physicians’ payments will be reduced 1.5 percent for not reporting PQRS
measures, with a 2 percent reduction in 2016. After 2010, physicians can use
PQRS reporting to satisfy maintenance of certification requirements through the
American Board of Medical Specialties (tying care measure reporting to
maintaining board certification). By January 2012, PQRS reporting is tied to payments
for physicians implementing electronic health records. Beginning in January
2012, Medicare will assign a VBP modifier based on quality measures and cost of
care to every participating physician. This payment modifier will be used to
determine Medicare physician payments beginning in January 2015. Private health
insurers are following suit. Again, for physician payment, this is about a 9-year
period from payment for reporting to payment based on care measures.
You might ask, “Who is
creating all these measures?” The Physician Consortium for Performance
Improvement (www.physicianconsortium.org) convened and staffed by the AMA and comprised
of over 170 member organizations (specialty organizations) has approved 270 measures
in 43 clinical areas. The National Quality Forum (www.qualityforum.org/), contracted by Health and Human Services, has
approved 634 measures.
Hospitals have public
transparency for their core measures—hospital-acquired complications, readmission
rates and patient satisfaction scores on the Hospital Compare website (www.hospitalcompare.hhs/gov/).
Medicare is developing a Physician
Compare website for the 2012 implementation of physician-specific care
measures. Given that these measures are based on a 2-year history of your
practice, you may already be half-way through your measurement period.
Perhaps physicians
will be spared this emphasis on VBP physician payments and public reporting by
the Republicans promise to repeal the Health Care Reform bill. This rescue is
doubtful given that initial VBP laws were enacted during the Bush
administration and the Republican’s strong emphasis on reigning in government health
care spending.
Now, address the more
difficult questions of “What’s in it for the practicing physician?” and “Why
work with the hospital and payers to document the increasing number of care
measures?” Remember, it is clear that individual physician payment, continued board
certification and even public reputation will be based on physician-specific
care measures. The measures used to “grade” physicians will be the physician-attributed
hospital Core measures: hospital-acquired complications, readmission rates, PQRS
measures, and patient satisfaction scores.
In reflection, it may be appropriate that judgment about our care is based on evidenced-based measures developed with input from physician groups. As physicians, we understand the limitations in determining “evidence” in a field that is as much art as science. What is clinical “gospel” today may be “heresy” tomorrow. But this focus on evidenced-based care may be the chance for physicians to take control of how medicine is not only practiced, but compensated. Adherence to evidence-based standards (or documentation for appropriately deviating) is what is being requested by hospitals and payers, referring and covering physicians, nurses caring for patients and our malpractice carriers. This “tsunami” of Care reporting is rapidly sweeping over physicians. It behooves us to learn all we can and be proactive in working with hospitals and payers to develop and ensure compliance with evidenced-based care. Most importantly, it is what our patients expect and deserve.
Sincerely yours,
Jesse Moss Jr. MD
U.S. Senate
John Cornyn
(202) 224-2934 (210) 224-7485
http://www.cornyn.senate.gov/
Kay Bailey Hutchison
(202) 224-5922 (210) 340-2885
http://hutchison.senate.gov/
U.S. Representatives:
Charles A. Gonzalez, District 20
(202) 225-3236 (210) 472-6195
http://www.gonzalez.house.gov/
Lamar Smith, District 21
(202) 225-4236 (210) 821-5024
http://lamarsmith.house.gov/
Francisco “Quico” Canseco, District 23
(202) 225-4511 (210) 561-8855
http://canseco.house.gov/
Henry Cuellar, District 28
(202) 225-1640 (210) 271-2851
http://cuellar.house.gov/