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CMS program gives doctors a glimpse of P4P future

While it lacks financial incentives, the program gives volunteers a trial run in reporting performance data

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

By Christine Bahls

Last month, the Centers for Medicare and Medicaid Services (CMS) officially launched what may be a test run of a future pay-for-performance program: the Physician Voluntary Reporting Program.

The goal of the program is to get physicians to submit process and outcomes data on 16 quality measures, which range from documenting whether a heart patient is taking aspirin to checking an elderly patient's fall history within the past year.

The CMS plans to use the new program to fine-tune the measures used and the reporting process itself, looking forward to when Congress may mandate pay for reporting or pay for performance within the Medicare program. While the voluntary program comes with no payment incentives, participating does give physicians a relatively trouble-free way to get some experience reporting performance data. ACP worked with the CMS to influence the measures selected and the program's reporting mechanisms. (More information about the program is online.)

Trent Haywood, MD, JD, the deputy chief medical officer of CMS' office of clinical standards and quality, helped put the program in place. He recently spoke with ACP Observer:

Q: How did you choose the 16 measures?

A: We looked for those that had prior consensus. We looked at AQA [Ambulatory Care Quality Alliance] for the ambulatory measures and the NQF [National Quality Forum], which has endorsed measures for specialty care.

Q: Do participating physicians have to report on all 16 measures?

A: No, they can pick and choose. Different measures apply to primary care physicians, emergency department doctors, nephrologists and surgeons, so they're not pertinent to everyone.

Q: How do physicians report data on different measures?

A: We've developed worksheets for each of the four specialties. During the patient visit, a physician will go down the worksheet list and check off information relevant to that set of measures. When billing staff prepares the claim, they'll use what's checked off on the worksheet to note CPT II or G-code information on the bill. Then they submit the bill—not the worksheet—as usual.

Q: So physicians can use CPT II codes to report?

A: Yes and no. We wanted to get this program started—but there weren't CPT II codes available for every measure. So we devised G-codes, which are temporary.

However, on five measures that apply to primary care physicians, doctors can use either G- or CPT II codes. Those measures are checking hemoglobin A1c levels; checking LDL for patients with diabetes; achieving blood pressure control for diabetic patients; prescribing angiotensin-converting enzyme inhibitors for heart failure patients; and administering a beta-blocker at time of arrival for acute myocardial infarction.

Q: What's the benefit of using G-codes?

A: They allowed us to target a broader range of physicians, both general internists and subspecialists. But one benefit of CPT II codes is that both commercial and Medicare payers accept them, so we may phase out the G-codes eventually.

Q: How do physicians note if an eligible patient shouldn't be included in his performance data?

A: Each G- and CPT II code has an exclusionary code to let the CMS know whether the patient should be excluded from that report. Physicians can note whether exclusions are clinician-determined, patient-based or systems-based.

Q: Do practices have to update their billing software to participate?

A: Our goal was to have physicians be able to report without any such modifications. But some practices have said their clearinghouses, which batch and send claims to the CMS, are charging more if there are more than five lines per claim. We are working with physicians and vendors to address these issues when they arise.

Q: When will physicians receive their first feedback?

A: If they submit before June 30, they will have a report back by year's end. The CMS will generate reports at the level at which physicians register to participate—at the individual or group level, based on tax ID number. Physicians will get feedback on both their reporting and performance rates.

Q: Why should physicians participate?

A: For one, the ABIM is allowing physicians to use this performance data to receive credit toward meeting its practice performance self-assessment requirement. More broadly, doctors want to know how they can influence policy. This gives them the opportunity to give direction to a national program.

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The 16 measures

The CMS began accepting reporting on these 16 measures on April 1, 2006:

  • Aspirin at arrival for acute myocardial infarction
  • Beta blocker at time of arrival for acute myocardial infarction
  • Hemoglobin A1c control in patient with Type 1 or Type 2 diabetes mellitus
  • Low-density lipoprotein control in patients with Type 1 or Type 2 diabetes mellitus
  • High blood pressure in patients with Type 1 or Type 2 diabetes mellitus
  • Angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker therapy for left ventricular systolic dysfunction
  • Beta-blocker therapy for patient with prior myocardial infarction
  • Assessment of elderly patients for falls
  • Dialysis dose in end-stage renal disease patient
  • Hematocrit level in-stage renal disease patient
  • Receipt of autogenous arteriovenous fistula in end-stage renal disease patient requiring hemodialysis
  • Antidepressant medication during acute phase for patient diagnosed with new episode of major depression
  • Antibiotic prophylaxis in surgical patient
  • Thromboembolism prophylaxis in surgical patient
  • Use of internal mammary artery in coronary artery bypass graft surgery
  • Preoperative beta-blocker for patient with isolated coronary artery bypass graft

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