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

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CMS initiative paves way for physician pay-for-reporting

The voluntary program allows doctors to test the waters without a big investment in information technology

From the January-February ACP Observer, copyright 2006 by the American College of Physicians.

By Janet Colwell

This month, the Centers for Medicare and Medicaid Services (CMS) will launch an ambitious quality improvement program with voluntary reporting of patient data from physicians.

Among the measures in the CMS' new "Physician Voluntary Reporting Program" are several for conditions that internists frequently treat such as diabetes mellitus, congestive heart failure and coronary artery disease. While physicians are under no obligation to participate in the voluntary program, practices that choose to do so may get a sneak preview of CMS' future pay-for-performance plans.

Since the launch of the program was announced in late October, ACP has worked closely with the CMS to modify the program and make it less burdensome for internists to participate. Michael S. Barr, FACP, MBA, the College's Vice President for Practice Advocacy and Improvement, outlined program details for ACP Observer and explained how physicians can get involved.

Q: Why is the CMS introducing this program now?

A: The agency is advancing this voluntary program in 2006 that may form the basis of a future pay-for-reporting program. It is a way for the CMS to test their information systems and data analysis capabilities, as well as gauge physician interest and ability to participate.

Q: What does the CMS want to measure?

A: It is still unclear what the final instructions from the CMS will be, but we expect the CMS will ask physicians in several specialties to focus on a narrower set of measures than the original 36 the agency proposed in October.

Primary care physicians will likely be asked to focus on a set of five to seven measures. We expect most, if not all, of these measures will be from the set of measures endorsed by the Ambulatory Care Quality Alliance.

The CMS is looking for both process measures and outcome measures such as hemoglobin A1c control and achievement of LDL goals for patients with diabetes. For coronary artery disease, for instance, physicians might be asked to report on whether a patient who's had a heart attack is on a beta-blocker. ACP encouraged the CMS to focus on measures that have potentially significant clinical relevance, are the least burdensome and do not require significant health information technology.

Q: How are physicians supposed to report quality data?

A: Through the claims process. When physicians submit a claim to the CMS, they will also submit a code to indicate that they evaluated the patient on a particular measure. The CMS is considering using two types of codes: CPT-II codes and G codes, which were set up by the CMS.

Let's say the measure is whether a patient who has congestive heart failure is on an ACE-inhibitor [angiotensin-converting enzyme] or ARB [angiotensin receptor blocker] therapy. First the physician would have to identify whether the patient meets the criteria for congestive heart failure. Then the physician would look to see if the patient is on one of the two drugs. Depending on the answer to that question, the physician would choose the appropriate code to submit with the patient's claim.

Q: How do the new codes work?

A: For each measure, the CMS developed three or four G-codes. For the example above, there are three codes. One would be used to indicate that the patient was eligible for and is receiving an ACE-inhibitor or ARB therapy; a different code would be used to indicate that the patient is eligible but not on therapy. The remaining code would be used to indicate that the patient was not an eligible candidate for the therapeutic choices.

For some measures, there is a code to allow physicians to indicate that a patient has not been under his or her treatment for a sufficient amount of time. ACP has been advocating for the CMS to use CPT II codes, rather than G-codes, when they are available, for several reasons. One, there is typically only one CPT II code for a measure, and because commercial payers, who may choose to use the same measures for reporting, typically do not accept G-codes. That means physicians would have to report differently on the same measures based on a patient's insurance.

And for all CPT II codes, there are two exclusion modifiers that can be used to exclude a patient from the analysis based on medical reasons or due to patient choice, such as economic, social or religious reasons.

ACP expects that one upcoming modification to the voluntary program will be the CMS' acknowledgement that the agency will accept either G-codes or CPT II codes for a particular measure.

Q: How should practices prepare to participate in the program?

A: There's nothing to sign up or register for. Practices can just start reporting on the measures through the claims submission process after Jan. 1.

To do that, physicians need to set up their practice management system to accept the codes for the measures they plan to track. Practices may also have to revise their paper encounter form or electronic health record to accept the new information, and they may want to develop a reference tool to enable physicians to select the correct code for the measure or measures being reported.

Q: What are potential advantages of participating?

A: The program will give physicians an opportunity, should they choose, to pilot a relatively simple method of reporting data without investing in health information technology. Ultimately, something like this may form the basis for a pay-for-reporting program in 2007 or 2008.

Also, the measures being used are likely the same ones that commercial payers will be assessing, so participating may help physicians with commercial pay-for-performance programs.

The CMS will also try to generate educational reports for participating physicians as early as summer 2006. It is not clear whether these reports will include data allowing physicians to compare themselves to blinded data from other physicians or to national benchmarks.

Q: Any potential downsides?

A: There are some logistical issues to work through. First, physicians need to be aware of the patient eligibility criteria for each measure and how frequently to report on a particular patient for a specific measure. ACP has asked the CMS to clarify these points, especially the frequency of reporting.

Practice management systems have to be able to accept the new codes—G-codes and/or CPT II codes—and there will likely be some additional brief chart review at the time of a visit to select the correct code. These codes are in addition to indicating the appropriate CPT code for visits and procedures as well as specific ICD-9 codes. ACP will develop a simple reference tool for physicians for selecting the G-codes and CPT II codes, once the CMS announces the final measurement set for internal medicine.

For the latest information on the voluntary reporting program, visit the CMS website.

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