Medical Device Daily Washington Editor

Pay for performance, or P4P, is no longer a policy novelty but is not yet much more than a pilot project as matters currently stand. If the Centers for Medicare & Medicaid Services has its way, P4P will graduate from reporting performance measures to improving outcomes early in the next decade.

In a Nov. 26 statement published by the Department of Health and Human Services, value-based purchasing (VBP) was described in a report to Congress as "a way to continue transforming Medicare as a prudent purchaser of higher-quality healthcare" rather than as a payer for services. The VBP paradigm would go beyond the performance measures employed in the P4P pilot administered by Premier (Charlotte, North Carolina) and require performance outcomes in order to maximize Medicare reimbursement value.

As might be predicted, the performance assessment model will be no simple one-stage measurement.

According to the statement, the model would be based on a comparison to national scores for that year or on the previous year's numbers for that hospital. Whichever measure offered the greater apparent improvement would be the measure on which CMS would base its payments.

According to an April 12 paper published after a public meeting on the subject, "the proposed scoring model is specific to clinical process-of-care measures," but CMS was not yet in possession of 30-day mortality measures that the agency wants to incorporate into the program.

The recent statement from CMS was not clear on whether agency has obtained data to back such measurements.

As for the possibility that a hospital has boosted performance to its highest attainable level, the statement said that data from 2004 and 2005 "demonstrated the need for a different approach to set benchmarks and attainment thresholds for 'topped out' measures."

CMS proposed a rubric for making this determination in the April document, but the Nov. 26 statement was again unclear on how this might work in the current proposal to Congress.

Richard Coorsh, a spokesman for the Federation of American Hospitals (FAH; Washington), told Medical Device Daily that FAH members are "strong supporters of quality-based payments and appreciate that CMS chose an option that would assess performance measures on an attainment score or an improvement score."

"Our key concern has to do with issues that may be raised in the use of a budget-neutral funding mechanism," Coorsh said. FAH "would caution policymakers to proceed cautiously with policies based on budget-neutral funding mechanisms" because such mechanisms "could exacerbate the financial challenges for hospitals already struggling to improve their quality scores," Coorsh added.

Another bill for imaging hits House

The cuts to Medicare imaging enacted in the Deficit Reduction Act of 2005 were said to have been inserted in a House-Senate conference and hence not subject to the normal congressional scrutiny. This fact has inspired considerable ire on Capitol Hill, and a new piece of legislation seeks to overturn a portion of those cuts.

Rep. Joe Pitts (R-Pennsylvania) introduced a bill last year, H.R. 5704, that would impose a two-year moratorium on reductions in Medicare payments for imaging services, but budget pressures killed the move.

Whether the same imperatives will kill a new piece of legislation with more modest ambitions remains to be seen, but the short timeline to the end of the first year of the 110th Congress probably offers an imposing hurdle top passage.

Shelley Berkley (D-Nevada) recently introduced H.R. 4206, titled the Medicare Fracture Prevention and Osteoporosis Testing Act of 2007, to reverse cuts to the use of an imaging widely seen as the gold standard for detecting osteoporosis. Berkley's bill would turn back cuts to imaging using dual energy x-ray absorptiometry (DXA), and the bill has pulled in 41 original co-sponsors.

One also might count Siemens (Berlin) and Hologic (Bedford, Massachusetts) as two of the bill's supporters in as much as both firms are among several who are manufacture DXA systems.

By some accounts, DRA cut Medicare reimbursement for DXA to below the cost of the procedure, which is said to have led to termination of this service on the part of many physician and mobile clinics.

Given that some estimates peg the number of Medicare eligibles who actually get bone densitometry testing as low as 14%, the fear is that osteoporosis will create larger healthcare problems.

"In the U.S. today, one in two women and one in four men 50 and over will break a bone due to osteoporosis," said Ethel Siris, MD, president of the National Osteoporosis Foundation (Washington). "We need Congress to pass this legislation in order to assure that access to testing is preserved and that those at risk of devastating and costly fractures are diagnosed and properly treated," she also said in the prepared statement.

According to a recent study conducted by the Lewin Group (Falls Church, Virginia), reimbursing DXA at 2006 levels would save Medicare more than $1.14 billion over five years due to the reduced number of fractures from osteoporosis.

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