Endocrine Insider
March 21, 2007

State Voluntary Pay-for-Performance Programs Could Have National Implications
The Center for Medicare and Medicaid Services (CMS) recently announced its newest partner in a collaborative effort between the federal agency and voluntary state performance measures programs. According to the Los Angeles Times, the results of the program could eventually be used to create national physician performance measures (L.A. Times, March 15, 2007). The initiative, called the Better Quality Information to Improve Care for Medicare Beneficiaries (BQI) project, includes reporting data from five states--California, Indiana, Massachusetts, Minnesota, and Wisconsin. Claims data from the state pay-for-performance (P4P) programs will be used in conjunction with Medicare data to measure the quality of provider services.

California, the newest partner in this collaboration, has had a voluntary P4P program since 2003. In addition to rating physician groups, the program provides financial rewards for improving preventive care, something that has yet to be nationally operational in the private insurer market or Medicare program. Under the new collaboration, individual physicians filing claims either with Medicare or with California’s three largest commercial insurers—Blue Shield of California, Blue Cross of California, and PacifiCare Health Systems—will be rated on their performance. It is estimated that approximately 25,000 California physicians—almost the entire physician population in the state—will participate in the program.

Concern has been raised that physicians participating in P4P programs could be penalized for failing to perform measured services even when there is a legitimate reason not to do so. Claims data would not be able to capture this information. For example, claims data may reflect that a physician failed to perform cervical cancer screening on a seemingly eligible female. What the data would not show is that the patient has had a hysterectomy and so would not require this screening (L.A. Times, March 15, 2007). Federal officials have stated that they recognize using claims data is less than perfect, but believe it is a starting point to measure physicians’ care practices.

The Endocrine Society staff will continue to monitor developments in quality reporting programs, including the new Medicare Physician Quality Reporting Initiative (PQRI), a voluntary performance measurement program that is set to begin July 1, 2007. For details on the PQRI and a list of frequently asked questions, please go to www.cms.hhs.gov/pqri/.