ASH Practicing Physicians Advocate on the Hill
Robert Weinstein, MD, Chair, Committee on Practice
The current reimbursement environment is dominated by the scheduled cuts in
the Medicare physician fee schedule expected to take effect in 2007 and the
coming years along with a pay-for-performance train that has already "left
the station." The ASH Committee on Practice (COP) endeavored to get out
in front of these issues with its spring visit to Capitol Hill. This is
the third consecutive year that the Committee has met with members of Congress
and their legislative aides to give voice to issues of importance to hematologists
in practice, and this year the Committee met with representatives from Centers
for Medicare and Medicaid Services (CMS), as well.
As pay-for-performance (P4P) continues to gain momentum, the Committee is concerned
that P4P programs rushed to implementation without adequate planning and testing
may have unintended consequences. During its Capitol Hill Day, the COP urged
Congressional offices to ensure that specialist and subspecialist physicians
are able to participate in P4P programs and in the development of quality measures.
The Committee further urged that practice measures recognized by CMS be fully
tested and validated prior to their adaptation in the Medicare payment system,
and that whatever system is ultimately adopted be sufficiently flexible to permit
rapid updating of established measures when called for by new medical information
or improved standards of care.
The prevailing premise in Congress and within CMS regarding changes in Medicare
reimbursement for physicians and P4P is that they are linked. By a mechanism
not yet established, relief from the threat of annual decreases in physician
reimbursement will come, if at all, in exchange for a system whereby reimbursement
is somehow tied to physicians' adherence to measures of quality. CMS, insurers,
and other organizations are investigating performance and outcome measures across
specialties in search of combinations that will cut costs while delivering quality
health care. In the drive to launch such P4P programs, subspecialties have lagged
behind primary care practitioners, because, whereas several suitable metrics
have been validated for primary care (e.g., counseling patients regarding smoking
cessation, following hemoglobin A1c in diabetics, etc.), few have been validated
in subspecialty fields. The COP has been active during the past year in
ensuring that hematology has a place in the development of hematology-specific
metrics. The ASH P4P Task Force has worked extensively on evidence-based hematology-specific
quality metrics and continues to work with CMS and the American Medical Association's
Physician Consortium for Performance Improvement on finalizing the metrics (see related story below).
This year, CMS initiated a demonstration program for physicians to report on
16 performance or practice measures, dealing largely with primary care or prevention
services that are evidence-based and fairly simple to assess. Physicians who
participate in the Physician Voluntary Reporting Program (PVRP) submit data
on whether or not they provided the service being measured. CMS will collate
this data and report back to the participating physicians on their performance
as compared to their peers. There are no incentive payments being provided
to physicians that participate in 2006. Hematologists are not likely to
participate in this program, because none of the measures identified by CMS
relate to the services they provide when treating patients. Many specialists
are in a similar position – they would like to participate but none of
the measures relate to their practices.
Although it is a new program, the limitations of the PVRP clearly demonstrate
the need for ASH to advocate with Congress and CMS to include hematology in
the development of, and participation in, demonstration and pilot programs.
Although incentives or penalties are not currently tied to the PVRP, they will
be a part of P4P. The COP continues to work with stakeholders and legislators
to ensure that the concerns of practicing hematologists are recognized and addressed
in coming years.
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ASH Develops Quality Measures for Hematology as Pay-for-Performance
Initiatives Continue to Move Forward
Kenneth Adler, MD
Dr. Adler is Assistant Clinical Professor at the University of
Medicine and Dentistry of New Jersey. He was awarded the St. George National
Award by the American Cancer Society in 2002.
As we are all aware, recently Congress and the Centers for Medicare & Medicaid
Services (CMS) have become focused on developing a pay-for-performance (P4P)
program for physicians treating Medicare beneficiaries. Luckily, last year ASH
saw the writing on the wall and created a special task force as part of the
Committee on Practice to devise formal criteria for hematology-related performance
measures. Since then, the ASH P4P Task Force has worked closely with CMS
to develop appropriate quality measures for hematology and has submitted five
draft measures to the agency for review.
In January, CMS implemented the Physician Voluntary Reporting Program with
a "core starter set" of 16 non-hematology-related evidence-based measures
that have been reviewed by the National Quality Forum (NQF). The NQF is a nonprofit
membership organization designed to be the principal body that endorses national
health-care performance measures, quality indicators, and/or quality of care
standards. The second phase of the program is expected to include additional
measures once they have been approved by the NQF or the AMA Physician Consortium
for Performance Improvement (Physician Consortium).
In December of 2005, the AMA brokered a deal with the Congress that its Physician
Consortium would develop and approve roughly 140 performance measures by the
end of 2006. Physicians have the option of voluntarily reporting on how
well they do on three to five of these performance measures, beginning in 2006.
The AMA claims that this agreement with lawmakers averted a hasty shift to Medicare
pay-for-performance, but many specialty societies are critical of the initiative.
Concerns include frustration that the AMA negotiated a confidential agreement
and worry that some specialties may not be included at the table, either because
their organizations are not far enough along in developing quality measures
or because the focus on measures relates to primary care.
The Physician Consortium, in conjunction with the National Committee on Quality
Assurance (ACQA) and Mathematica Policy Research, Inc., will develop quality
measures. Once endorsed by the Physician Consortium, the measures are submitted
to the NQF for endorsement. The measures will subsequently be submitted to the
Ambulatory Quality Alliance (AQA). It is important to note that the Consortium
only submits measures to NQF when NQF calls for them.
ASH worked with the Consortium and CMS to achieve recognition for the intensive
work already accomplished with the Society's evidence-based hematology-specific
quality measures. Although focusing on measures related to general internal
medicine in 2006, the Consortium agreed to add ASH's hematology-specific metrics
to the 2006 agenda. ASH continues to work with the Physician Consortium and
CMS to further develop the hematology measures. Lawrence Solberg Jr., MD, PhD,
is the ASH representative to the Consortium and also participated in the ASH
P4P Task Force that developed the quality metrics. The four measures under
development are:
- Myelodysplastic syndrome (MDS) patient presenting with anemia (Hb <11
g/dl) had bone marrow examination including iron stain prior to receiving
erythropoietin therapy
- Diagnosis of chronic lymphocytic leukemia (CLL) confirmed and documented
by flow cytometry as part of patient's initial diagnostic evaluation
- MDS and acute leukemia patient whose initial diagnostic evaluation includes
cytogenetic testing on bone marrow or peripheral blood as appropriate
- Patient with multiple myeloma documented to be treated with a bisphosphonate
ASH continues the development of the hematology-specific quality measures with
the Physician Consortium and CMS with a goal of completing testing in 2007,
along with possible implementation in that year. Draft measures can be viewed
on the ASH Web site.
We strongly encourage all ASH members to give feedback on the measures. Comments
should be directed to Pam Ferraro, ASH Practice Advocacy Manager, at pferraro@hematology.org.
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Take Action
As this issue of The Hematologist goes to press, we mark the one-year
anniversary of the passage of the Stem Cell Research Enhancement Act (HR 810)
in the House of Representatives and one year of inaction on this issue in the
U.S. Senate.
HR 810 would expand the current federal policy on embryonic stem cell research
by allowing federal funding on stem cell lines derived after August 9, 2001.
This bill also establishes strict ethical guidelines for this field of research
by requiring that federal funds not be used to derive stem cells or destroy
embryos. ASH policy calls for support of federal funding of all avenues of stem
cell research under National Institutes of Health federal research guidelines
and with appropriate public oversight.
As each day moves closer to midterm elections, it becomes more difficult to
get a Senate vote on this important legislation. Now is a critical time to contact
your senators and urge them to pass HR 810 with no amendments and with no other
measures that restrict any avenue of stem cell-related research.
To join ASH's advocacy campaign and send a letter to your Senators, visit ASH's
on-line advocacy center.
Our system identifies your Senators for you and provides a draft e-mail message.
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News Headlines from Washington
CMS Releases Physician Update for 2007
The Centers for Medicare and Medicaid Services (CMS) now estimates that Medicare
physician fees will be reduced by 4.6 percent in 2007 under the current sustainable
growth rate (SGR) formula. The CMS rationale for the projected 2007 payment
rate can be found on the CMS Web site.
Congress has averted a physician pay cut for the last three years, and ASH is
working with others in the medical community to advocate for similar relief
in 2007. A major component of the ASH Committee on Practice Capitol Hill Day
included discussion with congressional offices about physician payment. However,
a legislative fix is complicated by the rising costs of averting cuts in the
physician update and making other changes to the SGR. According to recent estimates
from the Congressional Budget Office (CBO), freezing fees at 2006 rates would
cost $10.8 billion over five years. MedPAC has recommended replacing the SGR
with the Medicare Economic Index as an annual update mechanism for physicians.
However, new figures from CBO show that the 10-year cost of this change has
grown from $155 billion in 2005 to $218 billion. As such, Congress is not expected
to make changes to the SGR this year, but may enact another one-year payment
fix, probably tied to a pay-for-performance program.
House Passes FY 2007 Budget
The House of Representatives passed its FY 2007 budget resolution by a vote
of 218 to 210. Led by Representatives Mike Castle (R-DE) and Nancy Johnson (R-CT),
Republican moderates won a promise for modest increases in spending on health,
education, and other social programs. Republican leaders agreed to include the
additional $4.1 billion sought by the moderates for health and education programs
that must be offset with reductions in other areas. This funding is in addition
to the $4 billion that Appropriations Chairman Jerry Lewis (R-CA) already shifted
from defense and foreign operations to Labor-Health-Education. The House resolution
also excludes proposals by President Bush to reduce spending for Medicare and
Medicaid. ASH joined the health and research community in urging Congress to
add the $7 billion to the budget in discretionary funding for health, education,
and labor programs. The budget resolution is a nonbinding blueprint for congressional
appropriation bills and the first step in the annual federal budget and appropriations
process. Given differences over funding levels within the Republican party,
it is unlikely that the House and Senate will be able to reach agreement on
a plan for the fiscal year that begins October 1.
CDC Announces New Director of Division of Hereditary Blood Disorders
Roshni Kulkarni, MD, has been named the new director of the Division of Hereditary
Blood Disorders at the National Center on Birth Defects and Developmental Disabilities
at the Centers for Disease Control & Prevention (CDC). Dr. Kulkarni succeeds
Bruce Evatt, MD, who retired in 2004. The Division of Hereditary Blood Disorders
at the CDC is a national program directed at the prevention of the complications
of hemophilia, thrombophilia, bleeding and clotting disorders specifically affecting
women, and thalassemia. A long-standing member of ASH, Dr. Kulkarni most recently
was Professor at the Department of Pediatrics and Human Development and Director,
Pediatric and Adolescent Hematology/Oncology, College of Human Medicine, at
Michigan State University in East Lansing, Michigan. She has been a CDC collaborator
as the pediatric medical director of a hemophilia treatment center, thrombophilia
pilot site, and in women with bleeding disorders studies. In her distinguished
career Dr. Kulkarni has received numerous honors and citations, including the
College of Human Medicine Distinguished Faculty Award in May 2004, the National
Hemophilia Foundation's Award of Excellence Physician of the Year in November
2003, and the William B. Weil Jr., MD, FAAP, Endowed Distinguished Pediatric
Faculty Award in April 1999.
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