As the government begins to work on its “Comparative Effectiveness” plans for health care reform it is good to keep in mind some of the key elements noted in the summary listed below.  First, who will determine what is “effective” health care?  Second, while we may all feel we know what safety, efficiency, timeliness and patient centered may mean (if in fact any good definitions really exist) what or earth is “equity” in terms of evaluating health delivery by physicians.  All of these items speak to the concept of some Sovietization of health policy with health commissars reporting to the newly appointed Health Czar (perhaps that title is not an accident) and the comparative effectiveness committees making sure that “re-education” is accomplished so that physicians can continue to be licensed. Far fetched? Overly dramatic you say. Don’t bet on it if these health care reformers get their way . . . obi jo 

CMS hard at work on “reform”

Both the federal government and private payors are committed to moving from a payment system based on volume of services to one based on quality of services and efficiencies enacted (such as elimination of duplicative tests). Quality is determined by scores obtained on specific quality performance measures, such as those included in the recent CMS Physician Quality Reporting Initiative (PQRI). To date, the Medicare program has linked quality to payment through “pay for reporting;” nursing homes, home health agencies, health plans, dialysis facilities and hospitals all have current payment tied to the provision of reports on identified quality measures.

The PQRI is simply the physician version of this same general approach: physicians who voluntarily report on three or more applicable measures are eligible to receive a 2 percent bonus. The only way in which this program differs from those of the other providers is that it is still voluntary, at least for now.

However, Congress has taken a number of steps to ratchet up pressure in this area. In the Medicare Improvements for Patients and Physicians Act (MIPPA), passed in July 2008, Congress required the Centers for Medicare & Medicaid Services (CMS) to submit a detailed plan by May of 2010 for physician value based purchasing (PVBP). A similar plan was required of CMS by Congress for hospitals in early 2008. Recently, Senator Charles Grassley (RIA), ranking member of the powerful
Senate Finance Committee that has jurisdiction over Medicare, has been circulating a bill designed to enact key provisions of that hospital plan. It is anticipated that Congress will follow suit once CMS delivers the required physician plan in 2010.

What is value based purchasing?
Simply put, value based purchasing is the institution of payment for performance, in contrast to the pay for reporting efforts noted above. According to a CMS Issues Paper released to the public in late November 2008, value based purchasing “….aligns payment more directly to the quality and efficiency of care provided by rewarding providers for their measured performance across the dimensions of quality.” The dimensions of quality to which the paper refers are the six goals of the healthcare system identified by the Institute of Medicine (IOM) in its 2001 report, Crossing the Quality Chasm: safety, effectiveness, efficiency, timeliness, patient-centeredness and equity.

While CMS has launched a number of demonstration projects and other initiatives that are pertinent to physician value based purchasing, it has not yet synthesized the information gathered from these multiple efforts into a coherent whole, nor has it yet moved forward with the plan for hospital value based purchasing. To prepare the plan required by Congress, CMS held a public “Listening Session” on December 9 to pose numerous questions to physician organizations and to obtain their feedback.

Four CMS subgroups – Measures, Incentive Structure, Data Strategy and Infrastructure, and Public Reporting – have been formed to work on the plan. These workgroups are still in their early phases; the listening session focused on the progress of each group and the many questions that must be answered prior to preparation of the report.