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ASH Looks to the Past and Plans for the Future of Pay-for-Performance
Lawrence A. Solberg, Jr., MD, PhD
Dr. Solberg is Professor of Medicine at the Mayo Clinic College of Medicine, Jacksonville, FL. He is also Vice-Chair of the ASH Practice Committee.
Discovery of the JAK-2 kinase mutation in myeloproliferative disorders brought Janus, the two-headed Roman god, to the attention of all of us hematologists. Janus sits right in January — looking back to the past and forward to the future.
Looking back, it was wise in 2005 for the ASH leadership to engage in the evolution of the pay-for-performance process with the Center for Medicare Services (CMS) and, more recently, the AMA-Physician Consortium for Performance Improvement. Had ASH not engaged, others might have done this for us, or there might have been no metrics for hematologists created for inclusion in the new Medicare Pay-for-Reporting program to be implemented this July — in which case much of our clinical work would not count toward the planned bonus. We now participate regularly with the AMA-Physician Consortium via the ASH Practice Committee’s Hematology Workgroup, led by Steve Allen, MD, as well as through membership in the newly formed Oncology Workgroup.
Looking forward, ASH will be launching an online educational campaign in the spring with information about the 2007 Medicare Physician Quality Reporting Initiative (PQRI) program, hematology measures, and reimbursement. The financial incentive for the 2007 PQRI will be a lump-sum bonus payment in mid 2008 of 1.5 percent of allowed charges for covered professional services from July 1 to December 31, 2007, reported to the CMS National Claims History file by February 29, 2008. It is important to note that the 1.5 percent bonus will apply to allowed charges for all covered professional services and not just those charges associated with the specific measures reported on by clinicians.
Total charges, including the beneficiary deductible and co-payment, will be allowed — not just the 80 percent paid by Medicare or the portion covered by Medicare when Medicare is the secondary payer. PQRI-covered services are those paid under the Physician Fee Schedule only. A payment cap that will reduce the bonus below 1.5 percent of allowed charges may apply when an eligible clinician reports relatively few instances of quality measure data or under other circumstances. Eligible professionals in hematology practices will include physicians, nurse practitioners, physician assistants, and clinical nurse specialists. To be eligible, providers must use a National Provider Identification (NPI) on all claims and must successfully report on a designated set of quality measures.
The 74 measures finalized for Medicare are available on the CMS Web site. Modifications or refinements will be allowed up to the July 1, 2007, start date, but no new measures for 2007 will be accepted. Of eight measures directed toward hematology and oncology patients, four were developed by ASH. The four developed for solid tumors include one measure applicable to both hematology and oncology patients.
Reporting by hematologists for this initiative will be based on the claims-based quality reporting system used in the 2006 Physician Voluntary Reporting Program, which ended on December 31, 2006. Clinicians will report the CPT category II codes or, if these codes are not available, the appropriate G-codes. Successful reporting will depend upon how many quality measures are applicable to the services furnished by the hematologist during the entire reporting period. If no more than three measures are used by the clinician, each measure must be reported in 80 percent of the cases in which the measure was reportable. Clinicians will be able to select the quality measures that will be measured in their practices, but CMS is advising that clinicians report on every quality measure that is applicable to their patient populations to increase the likelihood that they will reach the 80 percent satisfactory reporting requirement and to decrease the likelihood that they will be affected by a cap on their bonus payment.
Stay tuned to the PQRI section of the ASH Web site for future updates. Details related to the cap will be particularly important to understand. Like Janus, we can look back to simpler times, but we must also look forward. For the sake of our patients, their families, and our practices, ASH intends to remain engaged in a sustained effort to positively influence the pay-for performance domain.
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Process for Recertification: The Good, the Bad, and the Ugly
Jonathan S. Serody, MD
Dr. Serody is Elizabeth Thomas Professor of Medicine, Microbiology, and Immunology for the Program in Stem Cell Transplantation at the University of North Carolina.
Over the past fifteen years there has been an increasing emphasis on the credentialing of physicians from hospitals, insurance companies, and practice plans. As a result, obtaining board certification for a subspecialty discipline from the American Board of Internal Medicine (ABIM) has become critical to the success of subspecialty physicians, including hematologists. Starting in the year 1990, maintenance of certification in a subspecialty of internal medicine required completion of a certification program every ten years. This entailed passing modules that assessed medical knowledge or physical diagnosis skills in addition to a secure examination in that discipline.
Beginning in 2004 ABIM added additional modules that are required for maintaining certification called practice improvement modules (PIMs). PIMs are Web-based self-evaluation tools that guide physicians through chart abstraction, patient survey, and practice system inventory to establish a practice performance assessment for a chronic condition or preventive service. Initially, the physician abstracts data from the charts of at least 10 patients and compares his/her management of a specific clinical condition to guidelines set forth by national accrediting agencies or medical societies. Areas of deficiency are noted, and a plan is put in place to correct these deficiencies. The PIM is completed when the effect of the plan has been measured and the diplomate reports the results to ABIM. In addition to Maintenance of Certification credit, physicians who complete a PIM earn 20 CME credits.
Many large group practices already use this approach to evaluate whether their practice’s performance adheres to national guidelines for the treatment of chronic diseases. Previously, multiple guidelines were available for physicians managing patients with chronic illnesses such as hypertension, diabetes mellitus, and asthma, or for the assessment of procedural-based competence. However, completing a PIM in a subspecialty such as hematology for an academic physician was difficult in the past, as it required either querying patients or colleagues via a questionnaire regarding communication skills or a self-directed module that the physician had to generate on his/her own for a specific area of hematology. I’m happy to report that this is no longer the situation.
To assist hematologists, ASH has generated PIMs that assess the management of patients with multiple myeloma, idiopathic thrombocytopenic purpura, and myelodysplastic syndromes. I recently completed the PIM on multiple myeloma. It focused on multiple areas in the management of patients with multiple myeloma — whether or not one’s practice always obtains markers predictive of response to treatment such as beta 2-microglobulin prior to therapy; which staging system is employed by the practice and how that system is used in deciding on medical care; and whether patients are given bisphosphonates using accepted guidelines for efficacy and safety. The questions for this PIM take about two to three hours to complete for the minimum number of patients (10) that are queried. However, the entire process took me seven months to complete, as it required implementing and reporting the effect of the changes mandated for completion of the PIM. For our group, this centered on the need to use the same staging system for all of our investigators and a consistent approach to treatment based on that system. In the future, this should allow for more uniform management of patients with multiple myeloma by the physicians at our center.
These ASH PIMs allow hematologists the ability to compare their practice performance with national guidelines and to correct areas of deficiency. However, please remember that the PIM is not completed until a report is generated describing how the changes implemented affected care. I recommend that physicians who need to recertify make sure that they start the PIM at least one year prior to the expiration of their certificates.
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Control Your Destiny with the ASH ITP PIM
Kenneth Adler, MD, FACP
Dr. Adler is Assistant Clinical Professor at the University of Medicine and Dentistry of New Jersey. He is also a member of the ASH Pay-for-Performance Task Force, for which he was awarded the ASH Outstanding Service Award in 2006.
The practice of medicine continues to change dramatically and we as hematologists must maintain control of our destiny as best we can. Recertification is a fact of life for practicing hematologists who were certified after 1990. Amid the stress of a high-stakes, time-consuming exam, it can be daunting to try to fulfill the American Board of Internal Medicine’s (ABIM) self-evaluation requirements as well. In order to ease this process and ensure that the practice community is provided with fair and relevant criteria to measure performance, ASH has created hematology-specific practice improvement modules (PIMs). Now, the Society is pleased to announce the creation of its newest module — the ASH idiopathic thrombocytopenic purpura (ITP) PIM. This benign hematology module joins the malignant hematology ASH PIMs for myelodysplastic syndromes and multiple myeloma. The volunteer hematologists on the ASH Pay-For-Performance Task Force, of which I am a member, are hopeful that the ITP PIM will be the first of several common benign hematologic conditions such as anemia, thrombophilic disorders, and bleeding disorders that may serve as future PIMs.
As Dr. Serody details in the adjacent piece, requirements for hematologists enrolled in the ABIM Maintenance of Certification (MOC) program have changed. The new recertification requirements for physicians include the need to secure 100 self-evaluation points with 20 points earned in medical knowledge, 20 points gained through an evaluation of practice performance improvement, and 60 elective points. We the members of ASH are looking forward to demonstrating to the ABIM the high quality of care our members strive to achieve.
Each ASH PIM awards 20 practice improvement points, the number required for recertification, as well as 20 AMA category 1 credits. Each set of measures on the ASH Web site is accompanied by physician resources and educational materials. I must admit that even with my prehistoric computer skills I found the PIM Web site highly user-friendly and wish all our post-1990 members the best of luck.
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