2007 AMA House of Delegates Wrangles Over P4P, Other Issues

By Cindy Borgmeyer • Chicago
7/19/2007

Pay-for-performance, or P4P, sparked considerable controversy at the June 23-27 meeting of the AMA House of Delegates in Chicago, with participants debating several recommendations in an AMA council report on P4P, as well as a number of related resolutions.

The delegates also examined other issues, including store-based retail health clinics, serotonin reuptake inhibitor use by pregnant women and attempts to criminalize the provision of health care to undocumented residents.

Pay-for-Performance Programs

Opponents of P4P programs claimed at the meeting that such initiatives inherently interfere with the physician-patient relationship; others asserted that implementation of P4P is inevitable, and they advocated a proactive approach to "manage" the issue.

This latter approach is consistent with how the AAFP has treated the issue, said AAFP Board Chair Larry Fields, M.D., of Flatwoods, Ky., a delegate to the AMA house. He outlined key points of the Academy's policy on P4P and described the collaborative relationships the AAFP has built during the past few years among public- and private-sector entities with a stake in P4P.

Fields also pointed out that the AMA itself already has created policy on this issue that recognizes and addresses many of the concerns being raised.

Still, it's an issue that has many limited specialists on edge, said Dale Moquist, M.D., of Houston, chair of the AAFP delegation to the AMA house, after the meeting. That trepidation, he added, can be attributed to a number of factors:

basic resistance to change;
some insurers have instituted P4P plans, only to pull back from them later;
limited specialists have been largely sheltered from the quality movement in the past;
the July 1 launch of CMS' voluntary reporting initiative, which many in the health care community fear will soon give way to a mandatory program; and
mixed messages from the U.S. Congress, which leave some in the medical community thinking that federal legislators will step in and rescind P4P programs.

"Most family physicians and general internists have had more exposure to P4P programs than our subspecialist colleagues have had," said Moquist. "This already is happening in the real world.

"When managed care first started to take hold, most decisions were based on cost, not quality. The medical community said at that point, 'We stand for quality.' The managed care community and the government now are saying, 'Show us.' In other words, prove your quality. Some physicians take that as an affront to their integrity and Herculean efforts to take care of sick patients."

In the end, the delegates called for the AMA to

collaborate with interested parties to develop P4P initiatives that align with established AMA policy;
oppose the use of tiered or narrow physician networks;
study the risks and benefits of P4P programs, both large and small, and report back to the AMA house;
work with other medical and specialty organizations to develop alternative means to evaluate and improve care quality;
work with CMS to encourage and support pilot projects developed in collaboration with state and medical specialty societies that lay the groundwork for effective incentive-based quality reporting; and
advocate that physicians be permitted to review and correct inaccuracies in their patient-specific data before it is disseminated.

Retail Health Clinics

Store-based retail health clinics proved to be another contentious issue among delegates, with many participants at a June 24 reference committee hearing denouncing the clinics as being little more than a ploy to lure consumers into a retail outlet.

"These clinics are being used as loss leaders, like milk in the gas station," said Illinois internist Kamran Hashemi, M.D., referring to a common marketing practice of underpricing an item to draw more customers into a store in the hope they will buy more profitable items.

Again, it was a representative from the Academy who offered a more moderate perspective. AAFP delegate Jun David, M.D., of Albany, N.Y., informed participants at the hearing about the AAFP's list of desired attributes for retail health clinics, a document that has engendered interest among and buy-in from some retailers.

In a similar vein, Jay Berkelhamer, M.D., president of the American Academy of Pediatrics, or AAP, urged reference committee members to include in their deliberations on this issue AAP statements that he said address "where (retail clinics) fit in, not just with the medical home, but in the appropriateness of care delivered."

After much deliberation and some last-minute fine-tuning on the floor of the house, delegates directed the AMA to

advocate that insurers and other third-party payers be prohibited from waiving or lowering copayments for patients who use these clinics;
ask state and federal agencies to investigate ventures between pharmacy chains and retail clinics, with particular attention paid to conflicts of interest, patient welfare and medical liability issues;
continue to work with state and medical specialty organizations to develop guidelines for model legislation to regulate operation of these clinics;
oppose waiving any state or federal regulations for these clinics that other medical facilities must abide by; and
continue to monitor these clinics and report back to the AMA house.

Other Issues Tackled

The delegates also adopted recommendations from a report from the AMA Council on Science and Public Health that examined serotonin reuptake inhibitor, or SRI, use by pregnant women. That report cited the following points as germane to discussions of this clinical topic.

Pregnancy does not protect against depression, and the likelihood of relapse is very high among untreated women with recurrent depression.
Maternal depression adversely affects child development, and prenatal depression may adversely affect birth outcome.
Transient postnatal behavioral abnormalities in infants of mothers treated for their depression during pregnancy have not been shown to result in long-term problems.
SRIs carry a small but significant risk for serious medical consequences.

The recommendations the delegates adopted call for the AMA to encourage further research on this clinical topic and monitor related activities among relevant medical specialty organizations.

In addition, the house called for the AMA to oppose legislation to criminalize the provision of health care to undocumented residents, including any measures that would require health professionals to obtain proof of citizenship as a prerequisite to care.

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