American College of Physicians: Internal Medicine — Doctors for Adults ®

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College taking lead role in pay-for-performance planning

From the March ACP Observer, copyright 2006 by the American College of Physicians.

With so many potential pitfalls in participating in pay for performance, physicians need a decisive voice in how programs are designed.

ACP has taken a strong role in that discussion--thanks in part to the efforts of Kevin B. Weiss, FACP, Chair of the College's Performance Measurement Subcommittee. Dr. Weiss is also ACP's representative to the Ambulatory Care Quality Alliance (AQA), a consortium of national stakeholders working to craft a standardized set of office-base performance measures.

Dr. Weiss spoke with ACP Observer:

Q: A recent Center for Studying Health System Change report found that many physicians are skeptical of pay-for-performance programs. Is that skepticism justified?

A: There's reason for concern because early pay-for-performance models were poorly implemented. Even current models don't yet have real evidence to show that they work. And we don't know all the unintended consequences, even when the models may improve patient care.

Right now, pay for performance is being driven primarily by employer and insurer interests without strong physician guidance, which probably leaves programs a bit unbalanced.

Q: What is ACP doing to represent physician concerns?

A: ACP is actually taking a very strong national leadership role. We're participating directly with the Ambulatory Care Quality Alliance, sitting down with health plans, purchasers and consumer groups to come up with common quality measures and reporting mechanisms. The AQA is making the quality agenda cleaner and more standardized, improving measures and deciding which ones should not be used.

We're also working directly with the CMS [Centers for Medicare and Medicaid Services] to help design a potential pay-for-performance program. Pay for performance is very much on the CMS' agenda, and if a Medicare program is launched, it will be a better program because of ACP's work with the CMS senior staff.

The College has also put a lot of thought into how such programs should be designed and has adopted extensive policy. ACP is now in the position where we're not just reacting—we're actually helping create national policy.

Q: How united is organized medicine when it comes to pay for performance?

A: Organized medicine seems to be in a state of transition. Some professional societies are just learning about pay for performance while others are well-versed in it and are resisting it.

The College has said, "We recognize this is part of the marketplace, so we are going to try to shape it." We're taking a very active, constructive approach as opposed to just pushing back or hoping that employers' and health plans' interest in pay for performance will fade.

Q: What can physicians do locally to avoid some common pitfalls?

A: Individual physicians can choose not to participate in pay-for-performance programs, but that might be difficult if the payer offering the program covers a significant percentage of their patients. If physicians have concerns about a particular plan, they should contact that plan's medical director to discuss those issues—or contact their state ACP Chapter, because other physicians may be having the same problems.

The AQA is encouraging payers to stick with the AQA-endorsed starter set of measures because those are relatively well-tested and can work in a number of settings. Directing the health plan to adopt the AQA starter set as part of their contracts is probably a good short-term solution.

Q: What common problems with programs do physicians need to be aware of?

A: One of the biggest questions is, 'does the program align incentives for physicians and patients?' Physicians should steer clear of programs that increase practice costs without providing enough incentives to offset those costs and to build in a positive margin that makes reporting worthwhile.

And employer-based health insurance is costing more for individual patients in terms of higher deductibles and co-pays. That means that patients already on the edge of what they can afford may opt out of certain recommendations their physician makes. Physicians should not be held accountable for any negative impact on care quality created by employer-based trends and shifting health care costs. We need to advocate for our patients and work to create incentives that can support a health care system that promotes quality.

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