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ACP Recommendations to CMS on Implementing its Doctors' Office Quality-Information Technology Demonstration Program

July 7, 2004

Mark B. McClellan, MD, PhD
Administrator
Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244

Re: Centers for Medicare and Medicaid Services (CMS) Doctors Office Quality-Information Technology (DOQ-IT) Demonstration Program, Implementing Section 649 of the Medicare Modernization Act of 2003 (MMA)

Dear Dr. McClellan:

The American College of Physicians (ACP), representing over 115,000 internal medicine physicians and medical students, is committed to working with CMS to see the DOQ-IT program succeed. ACP believes DOQ-IT represents a ground breaking attempt to improve quality of patient care by encouraging adoption of health information technology (HIT) in physicians' offices and providing a mechanism for clinical decision support and collection, measurement, and reporting of physician performance data. ACP strongly supports these efforts in a demonstration program. Our commitment to seeing DOQ-IT succeed has already led to two meetings with CMS staff, as well as encouraging all our California members to attend the June 23, 2004 DOQ-IT presentation in San Diego by Lumetra, CMS's lead Quality Improvement Organization (QIO) for DOQ-IT. Also, our California chapter has formally endorsed DOQ-IT to its members, providing them with detailed information on the demonstration, and urging them to become DOQ-IT participants.

Financial Incentives

ACP is pleased that, as a demonstration program, DOQ-IT is expected to offer financial incentives to encourage physician participation and adoption of HIT and point-of-care clinical decision support (CDS). ACP believes online, real-time access to patient data and CDS tools are critical for effective physician management of patients as they transit through different health care settings. We also believe that financial incentives to acquire such technology could potentially be a major positive factor in influencing physicians' decisions to participate in DOQ-IT and to acquire the necessary HIT and CDS tools.

At this point, however, it is unclear, what kinds of financial incentives will be available under the DOQ-IT program. Given the lack of definitive information on the financial incentives and the conditions for receiving them, it is going to be difficult to persuade physicians to sign up to become DOQ-IT participants (To illustrate, the Lumetra DOQ-IT website does not include any specific information on the financial incentives that may be available to participating physicians, yet Lumetra is actively recruiting physicians-with the support of ACP's California chapter--to join the program).

We strongly urge CMS to decide on the financial model that will be used to encourage physicians to participate in the DOQ-IT program and to obtain the necessary HIT and CDS tools. ACP specifically recommends the following:

• The financial incentives should be sufficient to offset a major portion of the costs of acquiring HIT (particularly electronic medical records systems) and CDS tools.

• Physicians should be eligible to receive the financial incentives simply by virtue of their decision to participate in DOQ-IT; the incentives should not be tied to how well they do on the required clinical performance measures or on whether they purchase EMR systems that include CDS tools. By linking the incentives to participation in the program, rather than outcomes, CMS will be able to determine how upfront financial incentives affect physicians' subsequent decisions on investing in HIT and CDS, when tied to an a broader program to encourage physicians to participate in performance measurement with HIT support.

• Ideally, the financial incentives should be offered to all participants. From previous conversations with CMS officials, we understand that the financial incentives may only be offered to physicians who are randomly assigned to a "test group" while other participating physicians may be randomly assigned to a "control" group that will not receive financial incentives. This approach may undermine physician support for the program because it will create "winners" and "losers" depending on a random assignment that is made after physicians are asked to make a decision on participation. Physicians who then do not receive the financial incentives are far more likely to drop out of the program and/or not make the desired investment in HIT and CDS.

• If the financial incentives are made available only to those who are randomly assigned to a test group, then physicians need to be clearly advised of the possibility that they may not be eligible for incentives at the time they are asked to participate. Those who are assigned to the control group (without financial incentives) should still be provided with dedicated consultative support from QIOs on office redesign to support performance measurement.

• The financial incentives should not result in budget neutrality cuts in payments to physicians who do not participate in the program (or offsetting cuts in payments to participating physicians for other services that they provide to Medicare). Any increased Medicare expenditures that result from the financial incentives should be incorporated into the sustainable growth rate (SGR) under the "law and regulation" adjustment. CMS should also recognize that the financial incentives may result in longer-term savings to the program.

Incorporation of Evidence-Based Clinical Decision Support

Evidence-based CDS tools, such as ACP's highly regarded Physicians' Information and Education Resource (PIER), help physicians ensure their patients' care choices are founded on the best clinical information and practices available, thereby raising the bar on quality. PIER also contributes to improved patient outcomes outside the physician's office, by increasing patient involvement in their self-care through take home physician-selected condition-specific patient educational print-outs. PIER is available online through the ACP website, and also in a physician digital assistant version and can potentially be integrated with electronic health record systems. ACP believes PIER is an outstanding product which would contribute to the success of DOQ-IT, and would be willing to work with CMS and its participating Quality Improvement Organizations (QIOs) on customizing PIER for use in the DOQ-IT demonstration. We encourage CMS to work with HIT vendors and the QIOs to make CDS tools, such as PIER, an essential component of the DOQ-IT program.

Appropriate Use of Performance Measures

DOQ-IT offers a first opportunity under Medicare to demonstrate that, given appropriate incentives to adopt IT and CDS tools to better serve their patients, physician clinical performance data can be used to achieve improved patient outcomes. In developing such performance related measures, ACP urges CMS to exercise extreme caution in how they are designed and utilized, to ensure physician's are not penalized for having a caseload with an inordinate percentage of complex patients (requiring an objective risk adjustment methodology), or for factors beyond their control, such as patients who are properly counseled about their prescribed care plans, but who are non-compliant.

Clearly, because DOQ-IT has the potential to substantially redefine how physicians manage their patients and are paid under Medicare, it is critical DOQ-IT be carefully designed and implemented. In this vein, ACP stands ready to work with CMS in the various ways described in the Attachment, which also includes some recommendations for CMS's consideration.

Summary

ACP believes DOQ-IT represents an exceptional opportunity to show how information technology, aided by real-time clinical decision support, can revolutionize the way medicine is practiced, simultaneously improving the quality of patient care and efficiency and productivity of healthcare delivery. In addition, it also offers the chance to prove the value of evidence-based performance measures, and to redefine the way physicians are paid. What is learned in DOQ-IT can clearly have national implications, and potentially improve the level and quality of care Medicare provides.

Realizing DOQ-IT's potential for positively impacting the delivery of healthcare, ACP is eager to be a front line player is this worthwhile endeavor, and offers our direct input and assistance in assuring DOQ-IT has meaningful results when its 3 year trial period concludes. In this vein, we have enclosed a series of three recent policy papers which bear directly on DOQ-IT's design, goals, and objectives.

ACP wishes CMS great success in this undertaking and would be glad to meet with you and your staff regarding this correspondence at your request. Please contact Bob Doherty, Senior Vice President for Governmental Affairs and Public Policy at (202) 261-4530 if we can be of further assistance.

Sincerely,

Charles K. Francis, MD, FACP, FACC
President

Attachments

1. ACP Recommendations on the Doctors Office Quality-IT Demonstration

2. ACP Discussion Paper: The Paperless Medical Office: Digital Technology's Potential for the Internist (March 2004)

3. ACP Policy Paper: Enhancing the Quality of Patient Care Through Interoperable Exchange of Electronic Healthcare Information (April 2004)

4. ACP Policy Paper: The Use of Performance Measurements to Improve Physician Quality of Care (April 2004)

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