Medicare Links Doctors' Pay to Practices - New York Times
The New York Times

--------------------------------------------------------------------------------
December 12, 2006
Medicare Links Doctors' Pay to Practices
By
ROBERT PEAR

WASHINGTON, Dec. 11 - After years of trying to rein in the runaway cost of
the Medicare program, Congress has decided to use a carrot instead of a
stick
to change doctors' behavior.

Doctors had been fearing a pay cut under Medicare, the health care program
for 43 million elderly and disabled, but Congress instead has offered
doctors
a small bonus with big strings attached. To get the money, doctors will have
to report how often they provide quality care, as defined by the government.

Lawmakers approved the change as one of their final acts before adjourning
early Saturday morning, and proponents said it would improve the quality of
medical
care.

But the plan immediately raised concerns among some doctors and lawmakers
who specialize in health issues. They said they worried that it could be a
step
toward cookbook medicine and could erode the professional autonomy of
doctors.

Doctors had been facing a 5 percent cut in Medicare payments in 2007.
Congress deferred the cut, freezing doctors' payment rates instead.

Now, doctors can qualify for a 1.5 percent bonus in the second half of 2007
if they report data on the quality of their care, using measures specified
by
the government. For example, doctors could be asked to report how often they
prescribe a particular drug after a heart attack or how well they control
blood pressure in patients with diabetes.

With these statistics, Medicare officials say, they will , in the near
future, be able to reward doctors who follow clinical guidelines and perhaps
penalize
those who flout such standards without justification.

For several years, Medicare officials have advocated a pay-for-performance
system, noting wide regional variations in the practices of hospitals and
medical
specialists. The idea was supported by the Bush administration and by
Senators
Charles E. Grassley
, Republican of Iowa, the chairman of the Finance Committee, and
Max Baucus
, the Montana Democrat who will be chairman next year.

"Medicare now pays the same amount regardless of quality," Mr. Grassley
said. Indeed, he said, Medicare "rewards poor quality," paying doctors to
treat
complications caused by their own mistakes.

But some influential
Democrats
, and even some administration officials and
Republicans
who support the general idea of pay-for-performance, expressed concern with
federal agencies setting benchmarks for care.

"This is a very significant step," Catherine G. Cohen, vice president of the
American Academy of Ophthalmology, said Monday. "It's the first time
Medicare
has ever paid individual doctors a differential for reporting quality
measures. It could impose a significant new burden on doctors' offices."

The legislation has created strange bedfellows.

Some doctors, health policy experts and politicians, including liberals like
Representative Henry A. Waxman
and conservatives like Robert E. Moffit, director of health policy studies
at the Heritage Foundation, are apprehensive. Beyond broader questions about
whether the government can accurately measure the quality of care, they are
concerned about the feasibility of developing standards for hundreds of
thousands
of doctors within six months. The quality reporting system begins on July 1.

In an interview, Mr. Waxman, a California Democrat who has been working on
health policy for more than three decades, said: "I am very skeptical of
pay-for-performance.
I'm not sure we can measure quality and performance that well."

Representative Pete Stark of California, who will become chairman of the
Ways and Means Subcommittee on Health in January, said, "The entire concept
of
pay-for-performance is offensive." Doctors, Mr. Stark said, are supposed to
provide "quality care" and should not be paid extra for doing so.

Moreover, he said, federal officials "do not have the capability, the
understanding, the knowledge or the training" to set standards for the
quality of
care.

Representative Charlie Norwood, Republican of Georgia, led efforts to enact
a "patients' bill of rights," saying insurance companies should not tell
doctors
how to practice medicine. He objects just as much to government efforts to
define quality.

"When government bureaucrats determine what good medicine is, instead of
patients and doctors, I get very suspicious," said Mr. Norwood, a dentist.

The administration says Medicare should not simply pay for more services,
but should reward doctors for efficiency and high-quality care.

Representative Nancy L. Johnson, Republican of Connecticut, also championed
the idea of pay-for-performance. But in an interview, Mrs. Johnson said she
was disappointed that Congress had not gone further to ensure that doctors
would develop the criteria for measuring quality. "Bureaucrats must never be
allowed to dictate medical practice," she said.

This concern is shared by some administration officials. In a recent speech
to the
American Medical Association
, Dr. Scott Gottlieb, deputy commissioner of the
Food and Drug Administration
, said he worried about intrusions into the practice of medicine by federal
agencies, including his own.

The original Medicare law, passed in 1965, said, "Nothing in this title
shall be construed to authorize any federal officer or employee to exercise
any
supervision or control over the practice of medicine."

Mr. Moffit of the Heritage Foundation said the new initiative was "a
backdoor attempt to repeal" this guarantee.

"It's pay for compliance, not pay for performance," Mr. Moffit said.
"Doctors will be financially pressured to comply with government guidelines
and standards.
The integrity and independence of the medical profession could be
compromised."

Dr. Stephen C. Albrecht, a family doctor in Olympia, Wash., said Monday:
"Medicare has a good idea here, but has not put much money behind it. The
1.5 percent
bonus does not justify the extra effort required to do the quality reporting
that the government wants."

Some doctors, like anesthesiologists and thoracic surgeons, have been eager
to develop their own quality measures.

Over the last 17 years, the Society of Thoracic Surgeons has collected
demographic and clinical data on three million patients. Doctors say they
have used
the data to improve the quality of care.

Dr. Frederick L. Grover, president of the Society of Thoracic Surgeons,
said, "We have provided feedback to doctors, comparing their performance
with state
and national benchmarks, and in this way we have significantly reduced
mortality and complications."

When possible, Medicare officials are supposed to use "quality measures"
that have been endorsed by the private sector.

Despite the move toward pay-for-performance, Medicare payments to doctors
are unlikely to keep pace with inflation. Congress postponed for one year a
cut
in fees but did not change the Medicare law's formula for computing payments
to doctors. They face an even bigger cut next year, in the range of 5
percent
to 10 percent, ensuring that Congress will have to revisit the issue.

Representative Stark said, "Doctors and others who like pay-for-performance
have to remember that it's a zero-sum game." As a result, he said, most
doctors
will have to accept lower fees if Medicare is to pay bonuses to the best
performers.

Dr. Frank G. Opelka, a surgeon at the Louisiana State University School of
Medicine in New Orleans, said: "We fully support the goal of enhancing the
quality
of care, but this is a new program. It will take some time to get broad
acceptance by physicians."

Copyright 2006
The New York Times Company

Posted by Miriam V.