Experts have been touting the idea of “pay for performance” – paying physicians according to their performance – as an inevitable change that will revolutionize the health care system by improving care and lowering costs. But last fall, in response to pressure from Congress, the Centers for Medicare and Medicaid Services (CMS) moved to turn that idea into reality by requiring that such a system be in place by January 2006. The AMA, AAN, and other medical associations felt more work needed to be done first and negotiated successfully with the CMS to delay the initiative. The AAN has taken leadership on this issue and established the Quality Indicator Work Group and the Pay-for-Performance Work Group to spearhead the effort to develop and implement performance measures on behalf of neurology.
James Stevens, MD, a sleep disorders expert in private practice, is Chair of the Pay-for-Performance Work Group. Through his work on this committee, and as member of the AAN Quality Indicator Work Group and Vice-Chair of the AAN Practice Committee, he has facilitated or authored over 30 evidence-based guidelines in neurology.
Christopher Bever, MD, has been Chair of the Quality Indicator Work Group since 2003, which was established to develop ways to measure the work of neurologists. Dr. Bever, Chief of the Neurology Service at the VA Medical Center in Baltimore, has also spent over 20 years on the AAN Quality Standards Subcommittee.
Drs. Bever and Stevens discussed the program in interviews with Neurology Today.
WHAT IS PAY FOR PERFORMANCE?
Bever: It means that patient care is evaluated by a specific standard; if the treatment meets that standard, then the physician receives additional compensation. The term pay for performance refers broadly to reimbursement schemes in which payments for services are linked to performance goals for those services. Pay-for-performance programs may be used with health systems, hospitals, provider groups, or individual providers, and may be retrospective or prospective. In retrospective plans, a portion of the expected payment would be held back until the end of the reporting period and paid based on performance in a measure or set of measures. In a prospective plan, like the one being considered by Medicare, an additional payment for a visit or service would be given for applying a quality indicator. For example, in caring for acute non-ambulatory stroke patients, providers would receive an additional payment if they satisfied an agreed-upon indicator such as prescribing treatment to prevent deep vein thrombosis within two days of hospital admission.
HOW DID THE IDEA FOR PAY FOR PERFORMANCE ORIGINATE?
Bever: It was based on studies of the medical system and efforts to improve quality. In 2001 the Institute of Medicine published a report titled “Crossing the Quality Chasm: A New Health Care System for the 21st Century,” which showed that there was considerable room for improving medical care in the US, especially in the areas of patient safety, effectiveness, timeliness of care, patient centeredness, efficiency, and equity. The report emphasized that efforts to improve quality prior to that time based on public reporting and voluntary clinical improvement had had little effect. The report argued that you can't modify physician behavior unless behavior is linked to reimbursement.
WILL PAY FOR PERFORMANCE INCREASE OR DECREASE PHYSICIAN PAYMENTS? HOW WILL IT IMPROVE QUALITY WHILE ALSO LOWERING COSTS?
Stevens: In England, where the system has been implemented for primary care physicians, they have reported that their incomes increased due to adherence to quality indicators. Some argue that if we adhere to performance measures, the cost of medicine will come down because it will reduce unnecessary testing and improve patient outcomes, and therefore, reduce additional costs down the road due to inadequate care. I think physicians are fearful that these measures are just a ruse to cut down their reimbursement. Their concern is understandable, but I'm not sure that is going to be the case – it wasn't in the UK.
HOW CAN NEUROLOGISTS INTEGRATE INDICATORS INTO THEIR DAILY PRACTICE?
Bever: Let's say you saw a non-ambulatory patient with acute ischemic stroke and one of the indicators is that stroke patients should receive DVT prophylaxis within two days of admission. You would provide services to the patient, including ordering DVT prophylaxis. Under the system being considered by Medicare, you would bill for your care based on the standard levels of service and could also bill an additional amount for having ordered the DVT prophylaxis. In general, the billing form would give you two options: that you satisfied the indicator or you considered it but it didn't apply for medical, patient, or system reasons.
As with other billing, Medicare can audit the provider and will expect to see documentation to back up the claim. Auditors would expect to see a note ordering DVT prophylaxis or stating the reasons that it was not appropriate. If there is no documentation they are going to take money back.
DOES THAT TAKE AWAY FROM INDIVIDUALIZED CARE?
Stevens: No, because if your notes indicate you are not following a performance measure, there is an option on the form to explain why.
HOW WOULD ELECTRONIC MEDICAL RECORDS HELP?
Bever: They could help in several ways. First, the electronic medical record (EMR) can provide reminders of indicators related to a patient being seen. The program would generate “pop up” reminder boxes with indicators related to a particular disease. The EMR could also link documentation related to pay for performance directly to billing statements.
In addition, an EMR might allow you to more easily analyze your records and see the effectiveness of what you've done. I work in the VA, where we already have an EMR system. So for example, we can now look at average blood pressures of all our patients and say system-wide, we should be reducing the blood pressure of patients with hypertension.
WOULD THIS FORCE PHYSICIANS TO ADOPT EMRS?
Bever: No, because billing sheets can still be filled out manually. Medicare can't put out a program that requires electronic health records because so many providers don't have them. But having an EMR would make it easier for you.
HOW HAS THE AAN BECOME INVOLVED WITH THE INITIATIVE?
Stevens: The pay-for-performance initiative has been on the “radar screen” of the AAN for the past few years. The Practice Committee formed the Quality Indicator Work Group in 2003. This group initially worked with the evidence-based guideline committees (the Quality Standards Subcommittee and the Therapeutics and Technology Assessment Subcommittee) to review what guideline recommendations were supported by very solid, high-level evidence. These, in turn, would provide the basis for development of pay-for-performance measures for neurology.
CMS is not going to be the only entity to use performance measures. Some of the big purchasers of health care – the General Motors and General Electrics of the world – have been pushing this concept. They see what health care is costing their companies and they want to get a better handle on not only the cost, but also accountability for the quality of health care being provided. In addition, several insurance companies and health watch organizations have suggested them and in some cases, are already implementing performance measures. In the past, AAN did not have input in developing these measures. Now, CMS and other very large health organizations are asking the specialty societies for input. The AAN has been in discussions with private insurers (United Health and Aetna) regarding their performance measure development for neurologic disease management. These discussions are in their early phases, but the AAN is committed to ensuring that neurologists are being “measured” by fair, evidence-based, meaningful standards.
WHAT IS THE PROCESS FOR IMPLEMENTING CMS INDICATORS?
Bever: CMS initiated a pay-for-reporting pilot program this April, which is still taking place and includes 16 indicators for primary care and diabetes – none are for neurology. Recently, the CMS contracted with a research organization named Mathematica and with the Physicians' Consortium for Performance Improvement (PCPI), an AMA-sponsored organization that comprises all the physician specialty organizations as well as other stake holders. The Academy – along with CMS, the PCPI, and Mathematica – have so far developed 11 indicators for stroke, which were introduced in May. [See sidebar, “AAN Indicators on Stroke.”]
Stevens: The stroke indicators were chosen based on their high level of evidence. All physicians and organizations had the opportunity to comment on these and get back to the PCPI workgroup and CMS by August 25th. The indicators are available on the AAN Web site [www.aan.com]. The Academy has asked members to comment on any performance measures.
Bever: Now that the comment period is over, modifications will be made and sent to the National Quality Forum. That organization will review the indicators to make sure that they have the proper metric properties and then publish them on the National Quality Measures Clearinghouse, a database of approved measures. [The database can be found at www.qualitymeasures.ahrq.gov.]
NEUROLOGISTS SPEND A LOT OF TIME EVALUATING AND PROVIDING CONSULTATIONS FOR PATIENTS. HOW WOULD PAY FOR PERFORMANCE TAKE THIS INTO ACCOUNT?
Bever: There are already systems in place that put a value on the time that a neurologist spends consulting with and evaluating patients. We've had discussions on whether to emphasize certain counseling activities and give a bonus to neurologists who do that. In July, for example, the Academy published a practice parameter on predicting the outcomes of comatose survivors of CPR. One of the points involves counseling the family of a loved one in coma. So you could have a quality indicator on whether a family conference was held to discuss the prognosis and the neurologist might receive an additional payment for having done that.
WHAT OTHER PERFORMANCE MEASURES CAN BE DEVELOPED?
Bever: You can develop measures that cover the outcomes of care, the procedures of care, and the structure of care. For example, we would like to prevent deep venous thrombosis in non-ambulatory patients with acute ischemic stroke. So you might have a measure that looks at the occurrence of DVT in such patients – that would have to be in a large practice – and use that as an outcome measure. A procedure measure in stroke patients would look at whether appropriate patients were put on DVT prophylaxis in a timely fashion. An indicator related to the structure of care would address whether a managed care organization or facility had the medications and equipment needed for DVT propylaxis.
The diseases that most need measures are ones in which the cost of care is expensive and where there is variability in management that is not explained by evidence. If we make care consistent it is likely to be better and less costly. The AAN Quality Subcommittee is currently looking at which areas this would include. Because it takes a lot of work to develop indicators, you don't want to develop them for diseases that are very rare, that don't have any risk associated with them, and for which care is already well established and uniformly practiced.
WHAT ARE THE PROS AND CONS OF PAY FOR PERFORMANCE?
Bever: Some people feel that having quality indicators equates to cookbook medicine. And it certainly would be possible to develop a program that did that. I think the medical community must ensure that as we develop measures, we are preserving individualization of treatment as appropriate and that we are not negating the effect of physicians' judgment. That's why it's important that physicians become involved in developing indicators, because they best understand the issues involved in making medical decisions.
Another con would be a disguised reduction in reimbursements. To deal with that, there must be some transparency with insurers in terms of the amount that they are paying physicians and the ability to demonstrate at the end of a time period that the program was revenue-neutral and didn't reduce reimbursement overall.
On the positive side, physicians have an incentive to provide quality services because they will make more money if they do a better job. And using performance measures is a quantitative way of looking at the quality of care provided by any subgroup. It provides an objective way of comparing the care provided by neurologists to that given by other groups of providers.
WHAT ARE THE CHANCES THAT CMS WILL ADOPT THIS PROGRAM?
Stevens: Depending on what our legislators decide, the voluntary CMS program may expand in the next 1–2 years, or “pilot” pay-for-performance reimbursement programs may be initiated for physicians participating in Medicare/Medicaid programs. When the federal government will implement this is anybody's best guess. Certainly there is enough momentum for this coming from the private sector and the federal level that it cannot be ignored lest our members become “blindsided” by this fast-moving train.
Bever: The driver for this is that Congress sees pay for performance as a solution to the escalating cost of Medicare. If the medical community stops moving forward on this, Congress will decrease Medicare reimbursement rates. I think as long as there is a lot of financial pressure on the government, it's likely things will move forward.
AAN INDICATORS ON STROKE
The following indicators are expected to be approved this fall. Under pay for performance, neurologists who complete and document these measures – or at least explain though documentation why they did not complete them – would receive an extra payment from CMS-Medicare.
- Measure #1: Deep vein thrombosis (DVT) prophylaxis is used for ischemic stroke patients by the end of hospital day two.
- Measure #2: Deep vein thrombosis (DVT) prophylaxis is used for intracranial hemorrhage patients by the end of hospital day two.
- Measure #3: Patients who are admitted to a hospital with ischemic stroke or transient ischemic attack (TIA) are prescribed antiplatelet therapy at discharge.
- Measure #4: Ischemic stroke or TIA patients with atrial fibrillation are prescribed anticoagulant therapy at discharge.
- Measure #5: Patients with ischemic stroke whose time from symptom onset is less than three hours are considered for tissue plasminogen activator (t-PA) administration.
- Measure #6: Antiplatelet therapy is given to ischemic stroke or TIA patients by the end of hospital day two.
- Measure #7: All patients with a diagnosis of ischemic stroke are given a formal dysphagia screening before being given foods, fluids, or medications by mouth.
- Measure #8: Neurologists will document that they considered rehabilitation services for ischemic stroke or intracranial hemorrhage patients at discharge.
- Measure #9: Patients with ischemic stroke or TIA will undergo non-invasive carotid imaging before being discharged.
- Measure #10: Patients admitted with ischemic stroke or intracranial hemorrhage will be given CT or MRI tests within 24 hours of their arrival to the hospital in order to determine the presence or absence of hemorrhage, mass lesion, and acute infarction.
- Measure #11: Overuse Measure: Most patients who were diagnosed with ischemic stroke should not receive intravenous unfractionated heparin.