"If defining quality is left only to payers, there is cause for alarm," writes the AACU's Ross E. Weber.
Based on a partnership with Urology Times, articles from theAmerican Association of Clinical Urologists (AACU) provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions. Contact the AACU government affairs office at 847-517-1050 or firstname.lastname@example.org for more information.
Health care reform requires the simultaneous pursuit of three goals, according to economists and government officials. As defined by these non-medical experts, the so-called "triple aim" seeks an improved experience of care, improved health of populations, and reducing per capita costs. To measure patients' subjective experience on all three components, public and private payers, as well as clinically focused physician groups, are scurrying to define "quality." There is some urgency to this effort because the law that repealed the Medicare sustainable growth rate (SGR) formula requires physician payments to be largely based on quality as of January 2019.
If defining quality is left only to payers, there is cause for alarm. Two recent proposals from the Centers for Medicare & Medicaid Services (CMS) stray far from the Institute of Medicine's definition of quality: "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."
A public policy research firm working on CMS's behalf turned a blind eye to current professional knowledge by proposing that providers be penalized for recommending PSA-based screening for prostate cancer. Using the flawed U.S. Preventive Services Task Force recommendation against PSA testing as its primary source, the CMS contractor concluded that the intent of its proposal "is to discourage the use of PSA-based screening in the general population of men," and that less testing indicates better performance.
Next: Individuals, organizations mobilize in opposition to recommendation
Individual physicians and organizations representing urologists, including the AACU, mobilized in strong opposition to this recommendation. The AACU State Society Network secured support from 22 state, section, and subspecialty groups on a letter that disputes the proposal for medical and procedural reasons. The leaders of organized urology question the limited exceptions to the wide-ranging recommendation and warn, "CMS must not implement quality measures and screening recommendations derived without input from specialists in the related health condition."
In official comments submitted by AACU Health Policy Chair Jeffrey Frankel, MD, the AACU points to "the importance of an individualized decision on PSA-based testing between the patient and the physician." The letter continues: "Physicians should not be penalized for ordering a test that, while not perfect, has long been recognized as an important tool in the diagnosis of prostate cancer."
Likewise, urology caucus members and delegates to the AMA House of Delegates secured approval of a new policy for the influential national organization during its 2015 interim meeting. Resolution 225, authored by the AACU and AUA, calls on the AMA to, among other actions, "…continue to advocate for inclusion of relevant specialty societies and their members in guideline and performance measure development…"
CMS requested comments on another proposed quality measure in recent weeks that opens the door to mandated physician participation in Medicare and Medicaid. A "Request for Information" solicited feedback on a proposal to collect information on a physician's participation, or lack thereof, in Medicaid, health insurance exchange plans, and other activities. This data would be synthesized into a quality measure and factor into provider Medicare payments. In a letter to CMS, the AACU warned against such a measurement, asserting that the government's collection of such information may "…prompt physicians to stop treating Medicare patients…"
Non-clinical definitions of "quality" will play a huge role in post-SGR Medicare payment schemes. Physicians will find that they must check many more boxes to demonstrate the quality of their care. Urologists must continue to take action to ensure these quality measures do not harm patients and medical practices. Much more information on this subject will be shared during the 2016 Urology Joint Advocacy Conference, scheduled for Feb. 28–March 1, in Washington.
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