The Society for Vascular Surgery (SVS), a professional medical society composed of
over 4,600 specialty-trained vascular surgeons and other medical professions who are
dedicated to the prevention and cure of vascular disease, appreciates the opportunity to
comment on Sustainable Growth Rate (SGR) Reform: Questions for Feedback. The
following are comments on the questions that were posed by the House Energy and
Commerce Committee:
Phase I
1. What is an appropriate period of payment stability in order to develop and vet
measures and build the necessary quality infrastructure? SVS strongly believes
that there needs to be a five year period of payment stability, with annual positive
updates, which will also allow sufficient time to develop and vet measures and
build the necessary quality infrastructure. During the five years, there should be
specific activities, including the following:
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Research supported and performed by specialty societies regarding riskadjustment. Methods and various models for risk adjustment need additional
study before this type of reimbursement can be adopted;
Demonstrated progress on creation of patient registries that would track
outcomes, improve quality and could be used by the Centers for Medicare and
Medicaid Services (CMS) to set benchmarks in Phase II;
CMS assigning professionals to interface with physician societies in order to
assist in the creation of benchmarks;
CMS convening workshops and town hall meetings with physician societies to
review and reform physician documentation.
2. Considering the different levels of provider readiness, how do we balance the
need for a stable period enabling providers to build and test the necessary
quality infrastructure, while still incentivizing early innovators to move to
Phase II, with opportunities for quality-based payment updates? A five year
period of stability is important not only for physician payment, but also for those
specialties that have established few or no quality measures. It is especially
challenging for small specialties to afford the time and expense to develop measures
and measure groups using existing performance improvement methods. Along with
the National Quality Forum (NQF), other entities such as CMS in conjunction with
physician societies should be able to develop quality measures. Five years should
allow specialties that have not participated in this process along with those who
need additional support to achieve recognition of at least one or more preferred
practices as a step toward the creation of performance measures followed by
endorsement of these measures. If there are societies that already have the ability to
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set benchmarks, they should be able to do this in less than five years, but only on a
voluntary basis.
3. What does a meaningful, timely feedback process look like for providers?
What are adequate performance feedback intervals? No longer than one year
cycles should be established as intervals for a meaningful feedback process that can
be easily interpreted. Timely feedback after each cycle is critical and should be
available within three months. Feedback should be patient-specific with a
denominator and numerator and an opportunity to validate or invalidate
conclusions. Thus, there should be a functional 30 day appeals process which
allows physicians to refute incorrect data.
4. How should Peer Provider Cohorts be defined to ensure adequate specificity
while preserving adequate comparison group size and ability to develop
appropriate measurement sets? For example, is using the American Board of
Medical Specialties (ABMS) list adequate? Peer Provider Cohorts should be
defined using diseases or procedures rather than defined specialties. This would
capture those providers who cross multiple practice categories. One way to do this
is by using families of Current Procedural Technology (CPT) codes that would
provide cross-specialty comparisons. The “grade” could be determined by disease
or procedure regardless of the volume. Cohorts cannot be set up in a way that
would allow for or incentivize “cherry picking” of patients. The ABMS list is not
adequate because it contains specialty-designation errors and the same is true for
self-designated specialty codes.
5. Should the list of Peer Provider Cohorts also include patient, procedural or
disease-specific cohorts in addition to traditionally defined specialty
groupings? As stated above, Peer Provider Cohorts must include procedural and/or
disease-specific cohorts along with an accurate longitudinal analysis of patient care,
which should be the standard since best patient care is the highest priority.
Integrating procedural outcomes and patient management/best practice measures
would capture the value of care by physicians.
6. Under the proposed revision of SGR which emphasizes best quality practices,
non-physician providers who are currently paid under the Medicare payment
system are also expected to be rated on quality measures. Do these nonphysician providers need unique measurement sets compared to physician
providers? Non-physician providers such as Physician Assistants and Nurse
Practitioners should not have separate quality measurement sets. They should be
expected to provide the same quality care as physicians. As stated in previous
comments to the House Energy and Commerce Committee, SVS is opposed to any
kind of tiered medical system for reimbursement.
Phase II
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1. How should existing programs such as the Physician Quality Reporting System
(PQRS), Meaningful Use of Electronic Health Records (EHR) and the ValueBased Modifier Program (VBMP) be transitioned into the new system? Are
there aspects of the current systems that should be retained, modified or
discarded? As stated in our answers for the two previous drafts, SVS supports
quality programs that not only depend on the existence of quality measures and
sufficient reporting, but also on the appropriateness of measures, proper riskadjustment and the existence of a system that provides ease of reporting. SVS
supports a strategy that would streamline, simplify and integrate existing quality
reporting systems including PQRS and EHR as well as new reporting programs or
systems, such as the VBMP. The administration of a new Medicare physician
payment system should be streamlined, with integration of as many common
measures, data elements and reporting requirements as possible – the majority of a
physician’s time should be focused on patient care. A single menu of quality
measures to choose from would be ideal. Measures must be critically examined for
actual impact on improved clinical outcomes.
Also, PQRS is not ready to be used to determine payment until it moves from
process measures to outcomes measures. The inflexibility and low participation
rates of current quality program requirements reflect the importance of streamlining
participation in these programs, thus reducing the administrative burden that is
presently required. Any new payment and/or reporting system should not replicate
the reporting structure of these programs in their current forms. Although we agree
that parameters will need to be set to ensure that the information being collected is
meaningful, it is important to recognize weaknesses in the current programs and
ensure that there are additional options which are user-friendly and flexible in
regard to data collection of quality measures.
Any core or comprehensive measures must account for the difference between
specialist and primary care visits. Many specialist physicians, even if they are part
of a comprehensive care system, may see a large number of patients from outside
their own integrated system for focused specialty visits. Measures applicable to
general health maintenance (screening, immunization) should not apply to these
specialty visits for patients who are receiving their primary care outside of the
specialist physician’s own system.
Similarly, the VBMP needs attribution for tests and procedures that are beyond the
control of the physician. SVS believes it is imperative that the quality component
of the VBPM, which will initially assess both quality of care furnished and the cost
of care under the Medicare Physician Fee Schedule for groups of 25 or more
eligible providers, should be meaningful and relevant to each member of that group.
Otherwise, there will be no ability to use this modifier to improve an individual
physician’s quality of care for his/her patients. And, it is not appropriate for
efficient Medicare providers to be penalized by the work of inefficient Medicare
providers, even if they practice together. Thus, CMS should provide data on
VBPM scores by National Provider Identifier and by Tax Identification Number for
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all groups that are subject to this in 2015. SVS also recommends three years of
testing and provision of data before any penalties are instituted.
Finally, SVS does not support a requirement that reporting based on a certain
percentage or number of a physician’s patients. We strongly discourage a one-sizefits-all data reporting system in any program that is created. A rural and
underserved index, risk adjustment and a case-mix standard that can be used as a
benchmark should be included to “level the playing field”. For the index, there are
patient factors that affect outcomes which are beyond the control of physicians,
such as not making appointments with physicians because of cost and/or travelling
distance, not controlling weight, not stopping smoking, etc. that must be addressed
in some way that does not penalize the physician.
2. How do we align and integrate quality measurement and reporting with
existing and developing specialty registries? How can registries support
provider feedback and streamline provider reporting burden? SVS has made it
a priority to conduct multiple quality improvement initiatives for its members,
including the establishment of a registry to report PQRS measures. However,
requiring all physicians to use a registry to report quality measures would create an
unfunded mandate. Again, the quality measurement and reporting process must be
streamlined, data entry must be simplified and safe electronic transmission must be
enhanced. Also, the process should be made disease-specific and risk adjusted. In
order to capture all providers, claims data could be used where risk adjustment does
not apply by developing measures and measure sets for high volume index
conditions and using CPT II codes.
3. What Clinical Improvement Activities best promote high quality clinical care
and should those activities be required as an integral part of a quality-based
payment system? Along with registry participation, compliance with clinical
practice guidelines and participation in Maintenance of Certification, which
provides continuing education and life-long learning, will best promote high quality
clinical care.
4. What process or processes could be enacted that would ensure quality
measures/measurement sets maintain currency and relevance with regard to
the latest evidence-based clinical practices and care delivery systems? How
would these processes ensure that quality measures evolve with data
accumulation and advancement in measure development science and
appropriately account for the relative value of measures as they relate to best
possible patient care? The measurement endorsement process through NQF is
acceptable, but it is also long, burdensome and for some specialties, financially
prohibitive. NQF is very bureaucratic and does not have enough staff resources.
Most of all, its process lacks transparency, so all of these problems must be
corrected. One solution would be to use other entities such as CMS in conjunction
with physician societies to develop measures, allowing societies to create and
submit measures at least twice a year for approval within six months of submission.
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5. Quality measures are categorized into process, structural and outcomes
measures. Should these measures be differently weighted in a quality scoring
system? If so, how? Outcomes measures are the most important measurement of
quality and should have the highest weight when determining quality. SVS also
strongly supports MOC as discussed above. The majority of PQRS measures
continue to be process measures in which physicians are simply checking a box for
such things as smoking cessation. Structural measures assess features of delivery
organizations, the capabilities of professionals and the policy environment in which
health care is delivered. A structural measure is useful if there is evidence linking
an increased likelihood that a patient receives a process or that patient outcomes are
optimized. SVS also recommends examining the development, role and weighting
of patient satisfaction measures as part of a quality scoring system.
6. From a variety of backgrounds, providers newly enter or re-enter the
Medicare system throughout the year. Since these providers have no reference
baseline with regard to quality reporting in the Medicare system, how should
the system account for their payment during their “observation” year? SVS
believes the observation year should be a transition for providers who are new or reentering the Medicare system in which no data would be collected and no bonuses
would be awarded or penalties imposed, essentially instituting a “hold harmless”
agreement for the first year. By the second year, data should be collected, which
would be reviewed in the third year when either bonuses or penalties could be
imposed using an established benchmark.
7. Should public and multi-stakeholder input be used during the measure
development and selection processes? If so, are there current CMS or nonCMS mechanisms that could be applied? Similar to the CMS proposed rules’
comment periods that provide opportunities for public and multi-stakeholder input,
affected parties should be able to provide comments during the measure
development and selection processes. This could have a similar time frame to the
proposed rules’ comments – within sixty days of publication. This should give
stakeholders sufficient time to review measures and provide comments on their
selection.
8. In the interest of transparency, a public comment opportunity is vital to the
quality measure development and approval process. Are there current
mechanisms that are both substantive and nimble enough to meet the policy
framework in the discussion draft of the legislative language? As previously
stated, NQF must become more nimble and timely in its review of measures. A
good example is the three year process it took to get a hemodialysis vascular access
measure approved for PQRS. Part of the process was testing the measure in which
NQF could provide no direction to SVS about how to do this even though this was a
requirement for approval. SVS had to spend unexpected money on a consultant to
determine how to test the measure before it was finally approved. As stated above,
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additional problems with NQF are its lack of transparency and timeliness; the CMS
process is more nimble and user-friendly.
9. Please suggest methods of quality-based payment which meet the goals of
fairness and fidelity and one that promotes provider collaboration and sharing
of best practices to achieve a learning healthcare system. SVS supports using a
single benchmark that goes up and down based on clinical evidence. We have
concerns with “tiering” within a specialty where there would be “winners and
losers” within each specialty with as much as a 10-15 percent differential. SVS
believes that all vascular surgeons should have the opportunity to be “winners” by
starting with a baseline for all and then providing higher reimbursement for those
surgeons who are deemed to be higher quality providers using the following:
quality improvement, identification of appropriate resource utilization and
development of medically innovative treatments, among others. Baseline standards
should be established that are predicated on input from physicians and other
stakeholders and encourage a variety of quality measurement and improvement
activities, while not setting the bar so high during initial years as to exclude any
activities or organizations with an established record of achievement.
Within the fee-for-service model, we recommend adding an indication value to CPT
codes for urgency and diagnostic severity; both of these deserve higher
reimbursement than elective procedures and milder diseases. Specialty societies
that use these codes could be tasked with determining if indications’ incentives
could make fee-for-service more cost-effective. Another recommendation is
creation of a correct diagnosis bonus. The objective would be to incentivize good
clinical decision-making and avoidance of excessive testing without penalizing the
ordering of needed tests. Physician societies would identify diagnoses that could be
made with a lower number of tests than are usually performed. For this to be
implemented, legal protections including medical liability reform would need to
accompany these algorisms. If this is not done, such incentives would be eclipsed
with additional testing as part of defensive medicine.
For additional information or any questions, please contact Pamela Phillips, SVS
Washington Office Director at pphillips@vascularsociety.org or 202-787-1220.
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