Medicare Compliance & Reimbursement

The Centers for Medicare and Medicaid Services' (CMS) Physician Group Practice (PGP) project should enhance the quality of care delivery, while providing 10 large physician practices an opportunity to earn performance payments.

CMS started the Physician Group Practice (PGP) demonstration in April 2005 as part of a legislative mandate included in the State Children's Health Insurance Program Benefits Improvement and Protection Act of 2000 for the PGP demonstration, according to a report published on the Commonwealth Fund Web site.

The report is based on the proceedings of a conference held in Baltimore in 2006, sponsored by the Commonwealth Fund, CMS and the Agency for Healthcare Research and Quality, to provide PGP program participants an opportunity to:

• Inspect specific care management models, comprising methods for both implementation and evaluation of efficiency.

• Ensure information sharing among PGPs and develop a system to make sure that this process continues.

• Develop a plan for case studies and descriptive reports on successful care management models. The reports would be distributed among different physician groups to improve the quality and efficiency of health care.

The project, which is currently in its third and last performance year, has provided 10 large practices an opportunity to earn performance payments which would be awarded by CMS for enhancing the quality and improving the cost efficiency of health care for Medicare fee-for-service (FFS) recipients.

The objectives of the demonstration are:

• To promote the coordination of health care provided under Medicare.

• To encourage investment in care management processes so as to ensure efficient delivery of service.

• To encourage physicians by rewarding them for improving health care services and outcomes.

Practices from all four U.S. census regions (the Northeast, the Midwest, the West and the South) are participating in the demonstration, the report states.

Each practice has at least 200 physicians and altogether they constitute more than 5,000 physicians.

The PGPs include freestanding group practices, components of integrated delivery systems, faculty group practices, and a physician network organization including small and individual physician practices.

Collectively, these are the biggest providers of primary care services for more than 220,000 Medicare FFS beneficiaries, according to the study.

Participating PGPs receive incentives to provide efficient and improved health care to Medicare FFS patients. Both quality and cost-efficiency based performance indicators are used to calculate the performance payments.

Issues that pose a challenge to the successful implementation of the demonstration are:

• Speed: Speed of implementing interventions is the biggest challenge PGPs face, participants find. Organizing cost savings and quality improvement interventions quickly so as to show positive results has been difficult. It usually takes longer than expected to implement organizational changes and to motivate physicians, the report indicates.

• Uninterrupted and speedy flow of information: Data and reporting delays are another reason for concern. Getting rapid feedback of assigned beneficiaries is necessary for PGPs to evaluate the impact of specific interventions and revise them but till now it is difficult to achieve the rapid feedback.

• Compensation strategy: Non-physician and medical home programs should also be provided some type of direct reimbursement.

• Inclusions of other programs: PGPs want additional care management programs added, such as care management and multiple chronic disease care.

Resource: To view the report online, visit http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=668157.