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Physician Pay Will Soon Depend on Outcomes

 |  By cclark@healthleadersmedia.com  
   June 13, 2013

The Centers for Medicare & Medicaid Services is seeking feedback from doctors as it builds a model for reimbursing physicians based on actual outcomes rather than process measures.

The e-mail to physicians earlier this month wasn't unexpected. It comes around this time each year when the Centers for Medicare & Medicaid Services invites doctors to tell Uncle Sam how they should be paid.

This time, though, the phrasing of the "Call for Measures" request was different, and from many doctors around the country, I'm sensing a worried cringe.

That's because this time, under authority of the Patient Protection and Affordable Care Act and several ensuing regulations, the payer in chief will move from measuring processes of care to measuring actual outcomes to determine the size of physicians' checks.

"CMS is seeking a quality set of measures that are outcome-based rather than clinical process measures [that] fall into one of the National Quality Strategy (NQS) priorities domains where there are known measure and performance gaps." the agency's message reads in part.


See Also: MGMA: Physician Compensation Increasingly Based on Quality Measures


The deadline for submittals is July 1. CMS will mull them over and in a few months, issue new outcome measures and rules for the Physician Quality Reporting System, adding to or replacing some of the current 328 measures, which largely are processes of care.

"We're moving toward a point at which there's an expectation that a certain level of quality will be delivered, and that date is 2015," says Bruce Bagley, MD, interim president and CEO of TransforMED, a subsidiary of the American Academy of Family Physicians, which supports physicians in their development of medical homes.  "And they'll be using 2013 calendar year (performance) data… with the level of payment moving up or down, depending on the data."

Look for scoring of group practice data to be posted on Physician Compare as well, starting next year.

No longer will doctors have to simply check a box that they prescribed the drug they thought the patient needed or any of CMS's recommended process measures on the expanding federal list.

The time is coming soon when they'll have to show their patients improved, or didn't get worse, at least by some defined measures, if they want to receive their full Medicare reimbursement.

For example, instead of being scored on the basis of whether they ordered periodic hemoglobin A1c testing for all their patients with diabetes, doctors' quality of care might be gauged on what a percentage of patients with unfavorable A1c levels met a certain A1c threshold after treatment.

That's tough; we all know. Doctors can tell patients to lose weight or take their medication or exercise, but the advice often falls on deaf ears.

The PQRS program began in 2007 as a voluntary pay-for-reporting initiative, in which doctors received a 2% bonus for reporting on fewer than 70 process measures. Few participated at first.

"There was a lot of emphasis at first on process measures because they were easier to do, and physicians felt less threatened by that," Bagley says.

"But I think as time has gone on, everyone realizes the process measures, by and large, are most useful at a local level for quality improvement. If we're going to have a major effort to collect, aggregate, analyze and publish measures on a national basis, then it should be around a relatively few patient-oriented outcome measures," he says.

But if CMS starts measuring physician quality based on "what percentage of your patients have a hemoglobin A1c below 7, doctors start to get a little twitch because there's a lot that goes into that, including patients taking their medications, doing exercise, losing weight, and some of these things that are not perceived to be in the control of the physician," Bagley explains.

"Now, instead of just telling patients, 'Just try harder,' it helps to use known techniques to engage patients in their own self care, motivational interviewing, shared goal setting, contact between visits— all those things help patients get better results in the outcome measure," he says.

Payment will no longer be linked exclusively to care provided during an office visit.

I'm wildly speculating here, but imagine how far this might go for, say the doctor with lots of diabetes patients. Down the line, it might mean blood pressure control, a measure of expected-to-actual revascularizations, or even in the very extreme, how many patients with the disease were so poorly managed that they had to undergo an amputation. Or died.

That, of course would be drastic.  And no one I've spoken in recent days suspects it will come to that anytime soon.

But patient outcomes are already a pay-for-performance measure for hospitals, which are blamed and penalized for performance on excessive readmissions. Starting Oct. 1, 2014, they'll be penalized for higher rates of 30-day mortality for three diseases/conditions, and for central line bloodstream infections, and for a composite of never events such as pressure ulcers and blood clots.

Doctors now will have their turn to share the responsibility and the financial risk for keeping patients healthy and out of the hospital.

Bagley and many other physician leaders I've spoken with don't dispute that measurement should move from being primarily process-based to primarily outcomes-based. Eventually. 

But whether doctors should be measured alone, or in group practices, and by how many measures remains in dispute.

Now, in sessions that are probably filled with acrimony and tension, professional societies and registries are trying to come up with outcome measures that fairly reflect their procedural services, and distinguish good performers from those who might be better off finding another line of work. 

"The American College of Cardiology has a good measurement strategy and a good registry of outcomes for a large population of their members. They have this stuff figured out," Bagley says. "But that's not the case for other specialties."

For example, he says, "Think about the ear, nose, and throat doctor. We have some measures around otitis externa and sinusitis. But that doesn't come close to the range of things they do every day."

How do you develop measures for every specialty and subspecialty out there? That's a tough one.

I called Ted Mazer, MD, an otolaryngologist in San Diego and former president of the San Diego County Medical Society. No pun intended, but I got an earful.

"We're all eager to find guidelines that work, outcome measures that help patient care and cost-efficiency. But until they're ready for prime time, they're being used as economic squeezes," he says. "The government, the academies, the health plans are all trying to do it. But until these measures are ready, they should not be put to use as an economic vice on physician practice."

Realistically, in his specialty, he says, one could measure symptoms experienced by patients after ENT surgery, and there are good measures for chronic sinusitis. "Sinusitis is being heavily monitored right now to see if too much surgery is being done."

But Mazer, like several physicians I've spoken with, fears that if doctors are forced to document even more, they will spend less time on patient care.

"That's one of the things that's frustrating the hell out of physicians and causing them to talk about getting out of the practice," he says.

I know one thing for sure. The next few months of federal rule making will be very, very interesting.

CMS 2013 Physician Quality Reporting System (PQRS) Claims/Registry Measure Specifications Manual by HLMedit

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