Sunday, February 26, 2006

A(nathe)MA

The AMA does not speak for me. In fact, it does not speak for the majority of physicians in this country, with only about 28% of actively practicing US doctors counted in their membership rolls. It is an organization that has repeatedly shown that it is far out of touch with the average physician and patient. It was midwife and mother to the current RBRVS system that has distorted our reimbursement system into something only the IRS could love.

With the kind of "success" that the RBRVS system has achieved, only arrogance can explain the AMA's most recent decision to develop yet another Rube Goldberg apparatus with the government. This week it was announced that the AMA has contracted with the government to develop "Measures of Quality of Medical Care".

The American Medical Association has signed a pact with Congress promising to develop more than 100 standard measures of performance, which doctors will report to the federal government in an effort to improve the quality of care.
Oh joy! Wait, there's more!
"We are concerned that the push to measure quality will become just a smoke screen to cut costs and to reduce the resources devoted to health care," said Dr. Frederick C. Blum, president of the American College of Emergency Physicians. But leaders of the American Medical Association said they had agreed to help develop uniform measures of the quality of care because otherwise doctors would have dozens of disparate measures foisted on them by insurance companies, health plans and government programs.

Under the accord between leaders of Congress and the A.M.A., doctors groups are to develop "a total of approximately 140 physician performance measures covering 34 clinical areas" by the end of this year. In 2007, the agreement says, doctors will voluntarily report to the federal government "on at least three to five quality measures per physician." The agreement says doctors "should receive" some additional payment to offset the costs of collecting and reporting the data.
I get it -- the AMA believes that instead of letting the free market sort this out, with the input of a variety of specialty societies, only they are smart enough to get the job done. Of course, who do you think would be better at, say, coming up with a basic set of standards for preventing DVT in the postop total hip patient -- the AMA, or the American Academy of Orthopaedic Surgeons working in concert with hematologists, internists, etc. And of course the reporting will be voluntary, and whoever reports the right data, in the right form, will get a few extra bucks. And there is a pot of gold at the end of the rainbow, too! The "pay for performance" train is already rolling, as I have previously noted, and there is nothing that will stop it at this point. But should the AMA really be the sole arbiter of what clinical measurements are to be rewarded?

Well, forget what I'm quibbling about; with such a gee whiz, super duper plan, everybody must be on board, right? Uh, not really.
Medical specialists, including emergency doctors, orthopedic surgeons, neurosurgeons and gynecologists, said they wanted to improve the quality of care and were already developing performance measures. But they objected to the confidential pact, titled a "joint House-Senate working agreement with the A.M.A.," and its ambitious timetable for assessing doctors' performance. In a letter this month to Dr. Cady, the presidents of seven medical specialty groups said they had not been consulted or informed. "The A.M.A. acknowledged the existence of this agreement only after we uncovered it," it said, adding, "The A.M.A. agreed to the imposition of a pay-for-performance system" without getting an assurance that doctors would be adequately paid for treating Medicare patients.

In a separate letter to Congressional leaders, 10 national doctor groups representing a wide range of specialties said: "We are dismayed that an agreement was reached on issues that are critical to the future of our specialties and our patients without our participation or knowledge. The American Medical Association cannot be the sole representative for the groups who are paramount to the development and implementation of quality measures."
This sort of behind-closed-doors deal is just the right kind of inanity that keeps AMA membership plummeting --- and it will ensure that the "quality" measures they come up with are [1] likely to be ignored, [2] well out of date by the time they are published, and [3] unable to meet any objective measurement of success. Why? Because we deal in a world of trial and error, with real consequences. As Dr. Stuart L. Weinstein, a University of Iowa professor and president of the American Academy of Orthopaedic Surgeons, said "Performance measures need to be developed by specialty societies, then tested and validated, to confirm that they really affect patient care in a positive way."

What a great idea! Make sure that the quality performance measurements actually have some degree of validity before inflicting them on the public! Why didn't the AMA think of that? What we should be asking is why the AMA is so intent on pressing its version of quality measurements that it resorted to a confidential pact with a few members of Congress to seal the deal. It doesn't sound as if they are really out for the patients' best interests.