ACP: Governmental Affairs and Public Policy - AACP Describes Activities of the College to Promote Quality Improvement in the Medicare Program

Advocacy

ACP Describes Activities of the College to Promote Quality Improvement in the Medicare Program

July 26, 2005

Mark McClellan, MD, PhD
Administrator
Centers for Medicare and Medicaid Services
Washington, D.C. 20201

Dear Dr. McClellan:

Thank you for your July 14 letter requesting information from the American College of Physicians (ACP) on our activities to work with CMS in support of quality and performance measures. We also appreciated the update on CMS activities.

The College values the collaborative relationship we have with CMS in support of continuous quality improvement in the Medicare program. ACP firmly believes that the medical profession has a professional and ethical responsibility to engage in activities to continuously improve the quality of care provided to patients. The College was among the first medical professional organizations to support the concept of linking payments to physician performance on evidence-based measures. We recognize, however, that pay-for-performance cannot by itself lead to quality improvements if physicians in practice lack the capabilities to incorporate proven quality improvement methods in their practices.

Accordingly, ACP is actively engaged in initiatives to develop the health information technology infrastructure to support quality improvement. We serve on the boards of the Certification Commission for Health Information Technology and the Electronic Health Initiative; co-chair the Physicians Electronic Health Record Coalition (PEHRC), and are actively involved in the Connecting for Health initiative. We have developed recommendations for legislation to provide initial funding and sustained reimbursement support to help clinicians, particularly those in small practices, acquire and use HIT to support their participation in quality improvement projects. The College has joined with other stakeholders to submit proposals in response to Secretary Leavitt’s requests for proposals on standard harmonization and certification of electronic health records.

The College is also committed to providing practice internists with practical tools to help them improve quality. ACP’s Physicians Information and Education Resource (PIER) provides ACP members—at no cost to them—with access to “actionable” evidence- based guidelines at the point of care for over 300 clinical modules. PIER has also been incorporated into several electronic health record systems. PIER is currently in the process of aligning its evidence-based content to support a starter set of measures selected by the Ambulatory Care Quality Alliance (AQA). PIER is also creating paper order sets that imbed such quality measures in the order set, so that physicians who have not made the transition to electronic health records could still rely on PIER content to support their participation in performance measurement initiatives.

ACP’s Practice Management Center has developed resources to help internists go through the decision-making process on electronic health records and is in the process of working with other entities in the College to provide internists with tools and best practices to help them redesign their office processes to improve health care quality.

ACP is also directly involved in supporting several federal demonstration projects to improve quality. We are directly involved in implementation of the Chronic Care Improvement Program/Medicare Health Support pilots in Mississippi and Pennsylvania as authorized by Section 721 of the Medicare Modernization Act, working with the awardees to develop mechanisms to support physicians’ roles in coordinating and improving care of patients with diabetes and congestive heart failure. The College has also endorsed the Doctor’s Office Quality Information Technology (DOQ-IT) demonstration project and is working with the American Health Quality Association to support the 8th Scope of Work.

ACP’s long-standing commitment to evidence-based medicine and continuous quality improvement is also evidenced by our active involvement in the Ambulatory Care Quality Alliance (AQA), which in May 2005 took a major step toward improving the quality of the U.S. health care system by selecting a "starter set" of 26 clinical performance measures for the ambulatory care setting. The College is one of four original organizations that organized and convened the first AQA meeting in the fall of 2004 (the other three co-conveners are America’s Health Insurance Plans, the American Academy of Family Physicians, and the Agency for Healthcare Research and Quality) and we continue to serve on its steering committee.

The AQA, a national consortium of large employers, public and private payers, and physician groups, aims to improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring, reporting and improving performance at the physician level. The AQA also works to promote uniformity in order to provide consumers and purchasers with consistent information and to reduce the burden on providers. This approach is similar to the Hospital Quality Alliance, which involved a broad array of stakeholders with the goal of producing a standardized set of measures for inpatient care.

The AQA’s starter set of ambulatory care measures is intended to provide clinicians, consumers and purchasers with a set of quality indicators that may be utilized for quality improvement, public reporting and pay-for-performance programs. The rationale behind the measurement starter set is to allow physicians to get used to tracking a few simple performance goals, while more sophisticated measurements and implementation guidelines are developed. The AQA's starter set of measures represent the first of several generations of increasingly sophisticated performance measurement sets that can be used to measure quality of care in the ambulatory area.

AQA’s uniform starter set comprises prevention measures for cancer screening and vaccinations; measures for chronic conditions including coronary artery disease, heart failure, diabetes, asthma, depression, and prenatal care; and, two efficiency measures that address overuse and misuse. Except for the two efficiency metrics, the AQA limited its review to those measures that are currently under review by the National Quality Forum.

ACP, and the other members of the consortium, worked hard to ensure that the initial set of measures relied principally on administrative data that are readily available for most practices, thereby reducing the administrative burden of having to extract information from medical records. In addition, they ensured that the starter set met the standards of scientific validity, feasibility, and relevance to physicians, patients and purchasers. AQA participants are also beginning to seriously address the complex issues associated with creating the infrastructure for performance reporting. The AQA is also working on a model for aggregating, sharing and stewarding data that maintains appropriate restrictions on privacy and confidentiality, as well as principles for reporting information to providers, consumers and purchasers.

Through these and other initiatives, the College is laying the groundwork for Medicare value-based purchasing by educating internists on how to incorporate performance measurement and improvement in their practices, by providing them with evidence-based clinical decision support, by partnering with others to develop the health information technology infrastructure to support quality improvement, by providing internists with practical tools to help them redesign office processes to improve quality, and by gaining first-hand knowledge from federal demonstration projects and pilot programs on how to incorporate quality improvement in the Medicare program.

Finally, ACP testified last week before the Ways and Means health subcommittee in support of creating a legislative framework for value-based purchasing. We believe that such a framework should include several key elements, including a phase in of performance measures (starting with structural and patient safety measures, followed by pay-for-reporting of evidence-based clinical measures, and then pay-for-performance based on the measures themselves); repeal of the sustainable growth rate formula, which is fundamentally incompatible with performance measurement and improvement; positive updates for all physicians with higher payments for physicians who satisfy reporting and performance thresholds; and a cautious and deliberative approach to developing methodologies for public reporting that address potential unintended consequences for non-compliant patients, patients with low health literacy, patients in underserved demographic populations that are less likely to have regular access to a physician and comply with recommended treatments and medication therapies, and patients with more complex conditions. Our testimony also advocated that Congress, CMS, and the medical profession engage in a fundamental re-examination of Medicare’s per-procedure, per visit payment policies that create incentives for volume-based care and treatment of patients with acute illnesses rather than physician-guided coordination of team-based care of patients with chronic diseases. We look forward to further discussions with CMS on ACP’s recommendations on Medicare value-based purchasing and re-examination of dysfunctional Medicare payment policies.

Please let me know if you have any questions about the College’s activities and commitment to support continuous quality improvement in the Medicare program.

Sincerely,

Robert B. Doherty
Senior Vice President
Governmental Affairs and Public Policy