The AAFP has once again jumped into the policy-making arena on behalf of family physicians, this time with a calculated response to CMS' draft quality measure development plan(www.cms.gov) released late in 2015 and titled "Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs)."
Providing solid input into the creation of this plan -- as well as other proposed rules and regulations related to implementation of the Medicare Access and CHIP Reauthorization Act -- is extremely important to the AAFP because these drafts, once finalized by CMS, will guide how family physicians are paid for years to come.
"CMS should encourage the development of measures that demonstrate the value of primary care and that are particularly focused on comprehensiveness of care and continuity," said AAFP Board Chair Robert Wergin, M.D., of Milford, Neb., in a Feb. 29 letter(6 page PDF) to CMS Acting Administrator Andy Slavitt.
"More than any other specialty, family physicians are disproportionally impacted by the burden of measurement," said Wergin. "This burden is needlessly compounded by the lack of measure alignment across payers, the variety of specifications adopted by payers on similar clinical topics, and the lack of value provided to family physicians by existing measures."
- The AAFP recently responded to CMS' quality measure development plan and told the agency to develop quality measures that demonstrate the value of primary care.
- AAFP Board Chair Robert Wergin, M.D., called for quality measures that, among other things, rely on best evidence, face regular updates and show harmonization across all payers.
- He urged CMS to create measures that take into account patient compliance and the patient's role in his or her health care so as to provide a complete picture of the physician's performance.
Wergin took care to note the AAFP's strong leadership in the Core Quality Measures Collaborative, a group whose work was highlighted just weeks ago.
Regarding the integration of quality measures to support MIPS and APMs, Wergin noted the "considerable number of measures that impact family medicine" and called on CMS to carefully consider which of those measures to include in its plan -- and to use the AAFP's policy on performance measurement criteria as a guide.
For instance, that policy states, in part, that quality measures should
- respect patient's cultures, values and preferences;
- rely on best evidence;
- consider variations of systems and available resources across practice settings;
- evaluate cost, quality and appropriateness of care together as one package;
- provide methodology transparency;
- face regular updates, especially when new evidence is available; and
- show harmonization across all payers.
In addition, CMS should utilize and implement the core measure sets agreed upon by the Core Quality Measures Collaborative, said Wergin.
On the topic of clinic practice guidelines, "These should be developed using rigorous evidence-based methodology with the strength of evidence for each guideline explicitly stated," said Wergin. He added that physician performance "cannot be evaluated on outdated performance measures that do not reflect current clinical evidence."
He called for the development of clinical quality measures to track "intermediate outcomes" for patients who are making progress toward control of chronic conditions; for instance, measures that would indicate success in reducing hemoglobin A1c, blood pressure or body weight, or a patient's smoking cessation efforts.
"Population health and prevention is an important factor in family medicine," said Wergin, and family physicians engage with their patient panels "in a proactive way to identify gaps in care, identify high-risk patients and to provide care management."
However, global and population-based measures should apply only to accountable care organizations, large health systems and public agencies that are responsible for a large population of patients, argued Wergin; they are not appropriate for individual physicians or small group practices.
"If primary care is to be held accountable for the total cost of care, CMS must dedicate greater financial resources to supporting primary care practices. These practices need additional funding and access to timely and actionable data…" he added.
The AAFP urged CMS to take action in other areas; for instance,
- offer physicians multiple options for completing clinical practice improvement activities;
- push the private sector -- including electronic health record vendors -- to adopt electronic clinical quality measure specifications;
- work with the Office of the National Coordinator for Health IT to ensure that EHR vendors decrease the burden of data collection for measure reporting;
- ensure EHRs effectively gather, store and report patient generated data if that is to be measured; and
- continue ongoing work toward the harmonization of measures across payers.
Wergin directly addressed the uncomfortable topic of patients who purposely "choose not to participate in their health care."
He urged CMS to create measures around patient compliance that take into account the patient's role in his or her health care -- and thereby allow physicians and evaluators of performance to see the "total picture" of performance.
Measures could include adherence to prescribed medications, refusal of appropriate treatment and active participation in longitudinal treatment.
"Enabling this type of measurement allows physicians to account for those patients who lack engagement," said Wergin, and it effectively reduces the potential for adverse patient selection.
Lastly, noted Wergin, CMS must develop measures that serve to incentivize subspecialists and health systems to share timely patient information with their primary care colleagues.
"Family physicians are often the quarterback of the patient's care team -- coordinating and orchestrating their care across the medical neighborhood," he said. But too often, family physicians do not receive hospital discharge records or reports from subspecialists and emergency rooms in a timely manner.
This situation prevents family physicians from providing appropriate follow-up care to patients, said Wergin.
He encouraged CMS to develop measures that promote shared accountability across settings and across health care professionals.
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