CMS Data Adequate to Move Ahead with Doctor Profiling
Government officials told a House panel that adequate Medicare payment and other claims information exists to move forward with a system of profiling individual physicians' practice patterns, which supporters say could improve doctors' efficiency and the quality of care.
"We have sufficient information to begin the process of providing feedback to physicians," A. Bruce Steinwald, director of health care for the Government Accountability Office (GAO), said. "Medicare's data-rich environment is conducive to identifying physicians who are likely to practice medicine inefficiently."
Steinwald told a hearing of the House Ways and Means Health Subcommittee that CMS "has the tools to make statistically valid comparisons, including comprehensive medical claims information, sufficient numbers of physicians in most areas to construct adequate sample sizes, and methods to adjust for differences in patient health status."
Steinwald said that GAO's recently released study on physician profiling, Focus on Physician Practice Patterns Can Lead to Greater Program Efficiency, showed that a feedback process "could be an important part of a package of reforms aimed at future program sustainability." However, he said that congressional action would be needed to implement such a profiling process.
CMS Work
CMS is in the early stages of a long-term effort to use its data to measure resource use by specialties, services, and physicians, acting agency Deputy Administrator Herb B. Kuhn said.
"Greater volume of services does not appear to correlate with higher quality or improved outcomes," he said.
The agency has been doing a great deal of work in the evaluation area, and with the proper authority and resources, could by mid-2008 start a feedback process. "Churning the data" will be a smaller job than educating physicians about the feedback and how they compare to their peers, he said.
The agency has used physician focus groups to investigate ways to measure individual physician resource use so that quality is linked to care, he said.
"After initial resource use evaluations are made, it is important to engage individual physicians in discussions," on a confidential basis, about how their resource use compares to others, he said.
Kuhn said that CMS is working with medical groups, Congress, and MedPAC toward improving the physician payment system. The 700,000 physicians in Medicare face a 10 percent cut in pay for services in 2008 under the sustainable growth rate (SGR) formula.
Subcommittee Chairman Fortney Pete Stark (D-CA) told the hearing that his panel's goal is to move away from the SGR to "a more refined system to better control volume while also improving quality of care."
CMS Evaluating Software Products
Kuhn said that to organize data to allow for meaningful resource use comparisons, CMS is evaluating two commercial "episode grouper software products"--tools that organize different services furnished to a beneficiary into "clinically meaningful episodes" derived from diagnosis information in claims data. "When services are grouped, the total costs of all services involved when treating a condition or illness can be compiled," he explained. CMS is looking at reports issued by the software with physician groups to ensure that the information is meaningful and accurate.
The agency will release more information on the software and its resource measurement project later this year, including such issues as the use of severity adjustment; identification of appropriate comparison groups; and development of rules for attributing services to physicians, including diagnostic tests that are ordered by the physician.
The resources use work, as well as various demonstrations that CMS is required to undertake by statute, are part of the agency's efforts "to transform Medicare from a passive payor to an active purchaser of high quality, efficient health care services," Kuhn said.
Physicians should be compared to those who are in their specialty and geographic area, such as cardiologists in Boston, he said.
In addition, the profiling should look at quality in order to reward physicians who are truly efficient and provide high-quality care at lower cost, he said.
Beyond Profiling
Hackbarth offered three other ways to help with the rise in Medicare physician spending (which SGR tries to counteract), although he said none are "silver bullets." These were encouraging the use of comparative effectiveness information, care management coordination, and accurate pricing of Medicare services. Increased CMS funding would be needed to carry out some of these ideas. "Because there is so much to be done," he said, "substantial investment in CMS" is required.
On another potential cost-saving concept, Stark said that bundling could be used under the physician fee schedule for coordinated management of chronic illnesses.
Kuhn said that CMS's experience with bundling of services has been mixed, with more success with large groups, like hospitals or large physician groups that provide a wide range of services. However, it could be problematic for smaller or specialized groups with a limited set of patients.
"In general, bundling works very well," he said, and more research in the physician area is warranted.
Hackbarth spoke in favor of trying more bundling for physicians. "A larger unit of payment puts physicians at greater financial risk for the services provided and thus gives them an incentive to furnish and order services judiciously," he said. "MedPAC is examining bundling the hospital and physicians payments for a selected set of diagnosis related groups, which could increase efficiency and improve coordination of care."
More information is available on the Web at http://waysandmeans.house.gov/hearings.asp .
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