Medicare Compliance & Reimbursement

Quality reporting won't work unless Congress and CMS develop a national system, IOM says.

Pay-for-performance adoption will accelerate if government programs begin to mandate them, researchers say. Further, if government agencies--such as the Centers for Medicare & Medicaid Services--provide a uniform set of quality reporting guidelines, P4P implementation could be successful.
 
Standardized P4P measures may be the solution to many of the problems that the Center for Studying Health System Change discovered in its site visits to 12 communities during 2005.

CMS launched a P4P demonstration in early 2005 and "expressed support for Congressional efforts to integrate P4P into Medicare physician payments," HSC says. If CMS decides to go forward with integrating P4P into Medicare, Medicaid programs and private payers may follow Medicare's lead and adopt its quality measures. "Whether physicians like it or not, if the giant payers decide to put money into P4P, it will happen," HSC maintains.

Despite the National Quality Forum's endorsement of more than 200 performance measures and employer groups' implementation of tests for quality, common access, quality and efficiency measures "have so far eluded the health care system," according to a recent Commonwealth Fund report. The Institute of Medicine released a report called "Performance Measurement: Accelerating Improvement" in which it "declared that 'the existing patchwork' of measurement and reporting systems isn't working," the Fund says.

"A well-functioning national system that can meet the need for performance measurement and reporting is unlikely to emerge from current voluntary, consensus-based efforts, which are often fragmented and lack a consistent connection to explicit, overarching national goals for health care improvement," maintains IOM's Committee on Redesigning Health Insurance Performance Measures, Payment and Performance Improvement Programs.

Congress Plays A Vital Role In P4P

Congress should establish a new board under the Department of Health and Human Services--the National Quality Coordination Board--that would speed up the development of a standardized performance measurement system, IOM recommends. Further, Congress should appropriate $100 to $200 million from the Medicare Trust Fund to invest in the NQCB annually. "A recent study estimates that a national health information network would cost $400 billion over five years," but uniform data collection will likely cost even more, "and physicians fear the burden will fall on their shoulders," the Fund notes.