ACP: Governmental Affairs and Public Policy - ACP Comments on CMS Framework for its QIO Program's 8th Scope of Work (SoW)

Advocacy

ACP Comments on CMS Framework for its QIO Program's 8th Scope of Work (SoW)

January 23, 2004

Stephen F. Jencks, MD, MPH
Director, Quality Improvement Group, OCSQ
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244

Dear Dr. Jencks:

The American College of Physicians (ACP), representing over 115,000 doctors of internal medicine and medical students, appreciates the opportunity to comment on the Centers for Medicare and Medicaid Services (CMS) framework for its Quality Improvement Organizations (QIO) program's 8th Scope of Work (SoW). In general, we are very supportive of the QIO program's mission to accelerate quality improvement through a collaborative partnership with the health care community, including physicians. Your framework clearly places a major emphasis on raising quality through incentivizing and measuring provider performance, and helping providers adopt the advances in information technology needed to make such performance measurement possible. Consistent with ACP policy, we would urge CMS to ensure that all performance measures are evidenced-based, valid, and tested before widespread application.

In order to provide better guidance to CMS on the content of the final 8th SoW, we will need more detail and explanations on your framework, and offer the following comments which we hope CMS will address.

I. Goal for this SoW: Accelerate improvement

Item A—This states that QIOs will "seek to expand the number and work of institutions in each state who achieve near perfect levels of performance. As part of the assistance offered, QIOs will identify and work with providers who are motivated by market-based factors—public reporting and pay-for-performance." ACP would appreciate details on how CMS defines "near perfect levels of performance," and what standards will be applied to measure this performance. ACP would also like specifics on what "assistance" QIOs will offer to increase physician motivation to improve performance. ACP cautions CMS in making any judgments about the performance levels of physicians that do not respond to incentives or invitations to participate in QIO performance related initiatives.

Item B—As above, ACP would appreciate knowing precisely what "improvement assistance" means—is this monetary assistance, or some other types of incentives? ACP would also appreciate more information on how CMS would have its QIOs promote organizational culture change? Culture change does not automatically happen but requires the transformation of existing values, attitudes, and behavior patterns. People do not change for change's sake but have to have a reason that is compelling to them.

Item C—How precisely does CMS intend to implement C.3, "Enable primary care physicians to achieve excellence in the care of patients with chronic illness through adoption of information technology and redesigned care processes"? How will excellence in care be defined, and what is your definition of "redesigned care process"?

Adoption of information technology by itself does not per se translate into excellent patient care. Does CMS believe that all changes observed in the quality of care would be attributable solely to use of new information technology, without in some way crediting physicians for being better caretakers?

Lastly, ACP would appreciate it if CMS would explain what is meant by a "care message" as used in C.5.

II. Core contract content

ACP is highly supportive of CMS's stated goals relating to improving patient safety and working to reduce disparities between medically underserved populations and the general beneficiary population.

Item B—What does CMS mean when it says it intends its QIOs "to broaden physician office work to include additional preventive services"? A more detailed explanation would be appreciated.

Item E—ACP would urge CMS to ensure physician performance data NOT be disclosed to the public until several critical technical issues are solved, particularly adjusting for case mix severity and patients with co-morbidities, as well as ensuring that only elements of care over which the physician has complete control are measured. ACP also would caution CMS on how it assigns physicians to categories of performance such as "excellent," as well as rewarding such physicians with public recognition—the issue here is whether such performance distinctions are completely attributable to a physician's professional skills, and not the fact his patients are much healthier or much sicker than an average age/sex adjusted cohort.

ACP is also concerned that, if CMS calls a certain group of physicians "excellent" that the public will assume all other physicians are "poor" or should be avoided. We thus urge you to address all the foregoing critical technical issues through carefully designed pilot programs, before considering expanding performance measurement to the general physician population.

IV. Developmental contract content

ACP supports the six objectives in this section which focus on reducing unnecessary utilization of services and medications, reducing medical errors and malpractice claims, and improving patient safety and the quality of care. Again, we are most interested in the details of how CMS plans to implement these objectives, so that we can provide more meaningful input before the 8th SoW goes into effect. In particular, we are interested in details on how CMS will implement Item E—"Prepare physicians for performance measurement through work on the DOQ-IT Project." We would greatly appreciate an update on the status of this project's implementation.

V. Program Management

Though on the surface the concept of bringing in new QIO contractors and making the process of obtaining a QIO contract more competitive, ACP is concerned that dropping a QIO with a long established cooperative relationship with local providers may do more harm than good. Open communication and trust are hard earned and vital commodities, and these should not be sacrificed because a new organization offers a lower price or promises to do more, especially if it has no previous track record and has to build relationships with local providers from the ground up.

Summary

ACP appreciates the opportunity to provide input on CMS's draft framework for the QIO program's 8th Scope of Work. Unfortunately, this document lacks sufficient details on new QIO initiatives to permit more substantive analysis and commentary. ACP is supportive of CMS's efforts to develop mechanisms for evaluating and incentivizing physician performance, but strongly urges CMS to ensure:

Performance measures are valid and evidence-based, and only measure elements of care over which the physician has complete control (e.g., a physician does not have control over a patient's failure to take medications as ordered, or a nursing home's failure to prevent bed sores, etc.)
That any methodology developed to measure a physician's performance scientifically and statistically adjust for age, sex, case mix, complexity of managing a caseload including severity of illness and existence of co-morbidities, and socioeconomic and geographic factors which may affect incidence of disease, contagion, and attitudes about seeking out preventive care and delays in seeking treatment when needed.
That every effort be made to reassure patients that physicians who do not receive the highest or lowest performance ratings are still competent and capable practitioners worthy of consideration.

Please direct any questions regarding ACP's comments to Mark Gorden, Senior Associate for Regulatory and Insurer Affairs, at (202) 261-4544, or by e-mail at: mgorden@mail.acponline.org.

Sincerely,

C. Anderson Hedberg, MD, FACP
Chair, Medical Service Committee

Page posted: 01/30/2004