American College of Physicians: Internal Medicine — Doctors for Adults ®

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Politics calls for a compromise in tactics, not principles

From the June ACP Observer, copyright 2005 by the American College of Physicians.

By Robert B. Doherty

One of the toughest decisions any organization faces is deciding when to compromise its advocacy efforts to achieve necessary legislative objectives.

Compromise too much or too soon, and your organization loses credibility. Lawmakers and the public do not respect organizations that are so focused on being "players" in the political process that they sacrifice key principles on the altar of expediency. Even more importantly, an organization that puts expediency over principles will also lose its own members' support.

But a steadfast refusal to compromise can make an organization ineffectual, even irrelevant. Lawmakers ignore those who do not understand that compromise is inevitable in a democracy involving multiple stakeholders with different and competing interests.

ACP often faces such hard choices. The College has an essential—even non-negotiable—responsibility to adhere to those principles consistent with its core mission of enhancing "the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine." But what happens when the constraints of the political process require compromises on certain policy objectives to achieve a larger goal?

Payment reform negotiations

The current state of discussions with lawmakers over Medicare physician payment reform is an example of how the College must make just such decisions.

As reported in previous ACP Observer columns, Congress is dealing with two key and increasingly intertwined issues related to Medicare physician payments. One is the looming cuts in physician payments that will result from Medicare's sustainable growth rate (SGR) formula. Unless Congress acts this year, Medicare payments to physicians will fall an estimated 4.3% in 2006—and by 26% over the next five years, with internists slated to lose $46,000 per physician on average over that five-year period.

The second issue is Congress' resolve to move Medicare toward a "value-based" purchasing model, which means paying physicians and other health care providers, in large part, on their services' quality and efficiency.

This would be a radical departure from the current system, which pays physicians the same amount per visit or procedure regardless of the quality, effectiveness or efficiency of their care. Value-based purchasing may come in several different models, including:

  • pay for reporting, with Medicare rewarding physicians for reporting that they have the capacity to track the quality of care provided to patients through use of health information technology;

  • pay for participation, with the agency reimbursing physicians for participating in performance measurement and reporting programs that use evidence-based clinical measures; and

  • pay for performance, probably the ultimate goal of value-based purchasing. Medicare would pay physicians based partially on how well they deliver care that is consistent with evidence-based measures.

The SGR issue and value-based purchasing are now joined at the hip in the minds of key lawmakers and Medicare officials. They are sending a clear message to ACP, the AMA and other physician organizations that there will be no fix to SGR cuts unless that fix is tied to creating a legislative framework for initiating value-based purchasing.

It would be bad policy, they believe, to spend tens of billions of dollars to halt the Medicare payment cuts without ensuring that at least some of that money targets the value of purchased services, based on still-to-be-determined measures of quality and perhaps efficiency.

These dueling issues create a real challenge for the College and other medical organizations. If we don't participate in developing a value-based purchasing program that can improve quality—not just drive down costs—Congress and Medicare officials may create an unworkable structure that would violate key College policies.

If medicine isn't willing to "come to the table" and help craft such a program, Congress could walk away from fixing the SGR—which means the cuts would automatically go into effect. The worst possible scenario would be if Congress allowed the SGR cuts to take effect and created a value-based purchasing program that puts cost savings over quality improvement. That would impose another unworkable administrative burden on already stressed, under-compensated internal medicine practices—while at the same time paying them less.

However, participating in the framework's development has its own risks and challenges. Many ACP members have legitimate concerns about how pay for performance will work in the complicated world in which they practice.

They worry that Congress will use measures that are not scientifically valid and/or will penalize them for circumstances—such as patient non-compliance—beyond their direct control. They fear that pay for performance will create yet another regulatory hassle that will require more work to produce data of questionable value with little or no improvement in compensation.

And they are justifiably concerned that their practice—like most—isn't ready to begin reporting quality data, even if the quality measures themselves are valid. (See "Alliance adopts a uniform set of clinical pay-for-performance measures.") Many members could view a College decision to take a seat at that table as lending support to an effort they feel is not in their—or their patients'—interests.

The College's approach

ACP's leaders have carefully weighed these risks, and have decided that the perils of not participating far outweigh those of getting involved.

By participating in the Capitol Hill discussions, ACP can ensure that any initial framework is consistent with key policy requirements. We will work to make sure that the measures being considered are evidence-based, practical and feasible—and don't impose excessive administrative burdens on most internists.

We will advocate that any pay-for-quality program be phased in carefully, starting with creating positive reimbursement incentives for physicians who document their capability to track progress in providing care consistent with evidence-based guidelines. And we will insist that Congress provide at least two years of relief from SGR cuts in the form of positive updates, along with the ability to earn additional bonus payments based on the initial set of measures.

As the College engages in these negotiations, compromise is inevitable. ACP policy, for instance, calls for first testing pay-for-performance programs as demonstration projects before they become part of Medicare payment policy.

But to get relief from SGR cuts, we may instead accept a step-by-step framework that allows Medicare to begin incorporating some rudimentary pay-for-reporting elements into Medicare payment policy, even before those demonstrations are completed.

We know some policies can't be compromised. We know that quality improvement must drive performance measurement—but we also know that we can't count on the goodwill of others to ensure that quality remains paramount.

The College must be engaged to draw the line on any compromise that conflicts with our mission of enhancing quality health care and fostering medical excellence and professionalism. A compromise in tactics and short-term objectives may be needed to help us achieve a greater good, but standing by and allowing our key principles to be compromised will never be a good deal.

Robert B. Doherty is ACP's Senior Vice President for Governmental Affairs and Public Policy.

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