AMA Pay-for-Performance Agreement Stirs Debate


Specialty organizations are concerned that the American Medical Association is unilaterally setting performance goals that doctors will not be able to meet.

A recent agreement between the AMA and leaders in Congress outlines an ambitious 2-year time line for establishing performance measures, “to improve voluntary quality reporting to congressional leadership,” Duane M. Cady, AMA chair, said in a statement.

Dr. Cady signed the pact at the end of last year, although the details weren't publicly disclosed until several months later. The terms were outlined in a Feb. 7 memorandum from Dr. Michael Maves, AMA vice-president, to the state medical associations and national specialty societies.

The plan was cosigned by Sen. Charles E. Grassley (R-Iowa), chair of the Senate Finance Committee; Rep. Bill Thomas (R-Calif.), chair of the House Ways and Means Committee; and Rep. Nathan Deal (R-Ga.), chair of the House Energy and Commerce subcommittee on health.

If the plan goes through, physician groups will work with the Centers for Medicare and Medicaid Services to agree on a starter set of evidence-based quality measures for a broad group of specialties, with the goal of developing approximately 140 physician measures covering 34 clinical topics by the end of 2006.

The AMA has been working on these quality initiatives for some time, Dr. Cady said. “For the past 5 years, the AMA has convened the Physician Consortium for Performance Improvement, which includes more than 70 national medical specialty and state medical societies.” To date, the consortium has developed more than 90 evidence-based performance measures.

The consortium has not yet tested the physician measures; it has been working with several groups to do so, including the Ambulatory Care Quality Alliance, said Dr. Nancy Nielsen, speaker of the AMA's House of Delegates, at a press briefing. The alliance is receiving funding from the Agency for Health Research and Quality and the CMS to test 26 measures at six clinical sites, beginning May 1. Those measures include some developed by the consortium.

The pilot is crucial, because it will bring to the surface any “unintended consequences,” Dr. Nielsen said. Then, in 2007, doctors who report on three to five quality measures would see increased payments from Medicare. By the end of next year, physician groups should have developed performance measures “to cover a majority of Medicare spending for physician services,” the agreement said.

Other initiatives, such as working on methods to report quality data and implementing additional reforms to address payment and quality objectives, also were outlined in the agreement.

Dr. Cady said nothing in the agreement with the congressional leaders should be a surprise. “It involved only [those] commitments we had previously outlined to our specialty society colleagues.”

Yet some of the members of the consortium said they had no advance notice of the AMA's plans to sign this pact.

The American College of Cardiology said in a statement it was concerned about the closed process that led to the pact, but it was “also acutely aware of the political realities woven into the legislative process.

“Cardiology is fortunate in that it has performance measures developed for its specialty. The challenge will be in bringing medicine together to … draw these measures into a pay-for-performance model that facilitates true quality improvement and better patient outcomes,” said an ACC spokeswoman. She also cautioned that Congress must remain flexible and mindful of the realities of physician practice in relation to the timing and costs associated with the implementation of any model.

The real problem isn't about advocacy or the workings of the consortium. It's about meeting deadlines on clinical measures, Cynthia A. Brown, director of advocacy and health policy at the American College of Surgeons, said in an interview. “Not everyone is ready for [pay for performance].” Many primary care quality measures have been written, but it's a different story for subspecialties, “because their measures haven't even been developed yet.”

With this latest agreement, subspecialties now feel pressured to find their own groups of doctors to propose measures to run through the consortium's process by year's end, she added.

“This is a dust-up about nothing,” Dr. Nielsen said at the press briefing, adding that the specialty societies had been included on the performance measure development from the start. The initial measures won't cover all the specialties, but it was necessary to show Congress that the profession was serious about quality improvement by geting something started quickly, she asserted.

Dr. Maves noted that physician concerns about the CMS's initial draft of the physician voluntary reporting program had been interpreted on Capitol Hill as a sign of opposition to quality reporting.


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