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General Business IssuesHealth Plans Refine Specialty MD Pay-for-Performance Programs as CMS Releases 74 MeasuresReprinted from the May 14, 2007, issue of HEALTH PLAN WEEK (formerly Managed Care Week), the industry's leading source of business, financial and regulatory news of health plans, PPOs, and POS plans. Health insurers are continuing to refine pay-for-performance (P4P) programs for specialist physicians — but the multiplicity of programs from different payers is leading to confusion among some physicians, managed care industry insiders say. And that problem may grow worse as CMS launches its own P4P program targeting specialist and primary care physicians. One national standards-setting board says that MCOs can reduce the administrative burden on physicians by partnering with national physician and quality organizations to develop and implement P4P programs. CMS last month posted specifications for the 74 measures included in the 2007 Physician Quality Reporting Initiative (PQRI), a new program that establishes a financial incentive for physicians and other health practitioners to participate in a voluntary quality reporting program. Eligible primary care physicians and specialists who report the requested data for a designated set of quality measures may earn a bonus payment, subject to a cap of 1.5% of total allowed charges for covered Medicare physician fee schedule services provided during the second half of this year. Examples of the PQRI measures include:
CMS becomes the latest organization to measure and reward specialty physician performance. Meanwhile, the National Committee for Quality Assurance (NCQA), the American Board of Internal Medicine (ABIM), and Bridges to Excellence (BTE) have developed partnerships with health plans for specialty P4P programs. Competing quality initiatives from CMS and health plans can confuse physicians, says Nicholas Bonvicino, M.D., senior medical director at Horizon Blue Cross Blue Shield of New Jersey. By using chart audits, CMS's program "sets an expectation that will be very hard for us to satisfy," he says. The program is based on physician self-reported information, and Horizon concluded that if it were to adopt a similar model, the program would be too expensive and resource-intensive for physicians to audit charts, he adds. "I'm happy that CMS is recognizing pay for performance, but it's going to be very hard for the average small practice in my state to participate in," he says. "The real challenge for everybody is to develop better methods to capture clinical information in ways that won't be costly." Horizon Adds Two New Specialties to Program During the past year, Horizon added general surgery and ear, nose and throat (ENT) to its specialty P4P programs. The health plan now targets 12 specialties in its P4P programs, including cardiology and gastroenterology. Physicians who score in the top 15% of participating physicians have access to a richer fee schedule, according to Bonvicino. Endocrinology, nephrology and mental health are specialties that Horizon may add in the future, according to Bonvicino. "We would like to add more specialties to expand to as many practices in our network as we can," he says. "The limitations are reliance on administrative data and the prevalence of evidence-based medicine guidelines that are written in ways that resemble protocols, and involve disease states that are prevalent enough to have meaningful statistical validity." Horizon partners with both ABIM and NCQA in its P4P program. The insurer recognizes practices that receive NCQA commendation for cardiovascular care, diabetes or practice management. The health plan also has included in its quality components participation with ABIM's maintenance-of-certification program, which sets standards and certifies physicians who practice internal medicine and its subspecialties, such as cardiology, endocrinology and geriatrics. ABIM's Web-based practice-improvement module (PIM) program allows physicians to demonstrate how they use quality measurement in their medical practice, focusing on one of 15 areas such as hypertension, diabetes or asthma. ABIM President Christine Cassel, M.D., says that one of the goals of working with health plans is to reduce the administrative burden on physicians who have to report data to various organizations. "If health plans could give credit to physicians for something they are already doing, that would add value to it," she says. "This is a standard that is being established by the profession and specialty itself, rather than the health plan. So they [i.e., the MCOs] felt it had more credibility, not only with the doctors but the public as well." Bill Fried, M.D., chief medical officer for Aetna, Inc.'s Mid-Atlantic region, which recently expanded its physician P4P programs, agrees that various quality initiatives have the potential to puzzle physicians. "It is confusing when there are multiple measures and possibly conflicting ones, but I think the level of dialogue is raised by more and more people getting involved in these issues, he says. "Physicians now understand that the concept of pay for performance is here to stay, so it's important for them to work with organizations implementing these programs rather than resist them." |
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