Practicing Physicians Advisory Council (PPAC) UpdateDate: Sunday January 12, 2003This is an update on the recommendations of the Practicing Physicians Advisory Council. As you recall from previous mailings, the Practicing Physicians Advisory Council (PPAC) is a group of 15 physicians across the country who act as an advisory council on regulatory issues concerning Medicare and Medicaid. Medicaid Previously, PPAC had requested that HHS Secretary Tommy Thompson establish a National Medicaid Advisory Commission similar to MEDPAC to address physician payment issues in Medicaid and their effect on access and participation. At this meeting we were advised that the Department of Health and Human Services had elected not to adopt our recommendations regarding Medicaid access. In fact, we were notified that when PPAC's charter is renewed in June 2003, the administration plans to delete any reference to Medicaid from our charter and therefore delete our ability to discuss Medicaid issues. To my knowledge, there is no physician committee able to provide input on Medicaid issues. Oversight of Medicaid may be an issue that needs to be explored through legislative means. Medicare Fee Update Secretary Thompson also wrote a letter back to the Chair of PPAC, Dr. Michael Rapp, stating that he empathized with physicians about the negative update for 2002. He assured us through this letter that he felt the calculations were made in accordance with the law and that HHS had no flexibility with which to avoid the reduction. When Tom Scully made his remarks in this PPAC meeting, he commented that his department had gone back to 1992 and recalculated all of the updates, correcting the errors that had been made by CMS. His calculations suggested that if all the errors were corrected physicians would receive a 1.6% increase in fees rather than a 4.4% decrease. However, according to Mr. Scully, it is required that Congress fix the fee update. There are 60 days from the day of publication in the Federal Register for Congress to make comments. The final rule was in fact published in the Federal Register on December 31, 2002, with an effective date of March 1, 2003. Physicians Leaving Practice PPAC discussed the concern that as more and more physicians reevaluate their business options with the decline in Medicare fees and the increase in expenses they may find that it does not pay for them to continue in practice. We suggested that CMS conduct research on the cost of reestablishing a practice or establishing a new practice when physicians retire or move away. In the inner cities, small towns and rural areas where physicians decide they cannot make ends meet and leave their practices, it may be extremely difficult and expensive to induce new physicians to establish a practice. This will have a significant impact on the delivery of health care to seniors, even if the Medicare fees are increased in the future. Doctors Office Quality Project We heard significant testimony on the "Doctors Office Quality Project" (DOQ). We commend the idea of doctors office quality initiatives but were concerned that it might become another paperwork mandate and requested that the project take steps to minimize the paperwork and time required by participating physicians and avoid creating a financial disincentive to participate. We also recommended that CMS explore demonstration projects on the use of financial incentives to improve quality. We recommended that CMS continue to work with the AMA and the Physicians Consortium for Performance Improvement to ensure the proper development and implementation of evidence based clinical performance measures that enhance the quality of patient care and advance the science of clinical performance measures improvement; that information gleaned from implementing the measures in the pilot tests of the DOQ project be used to further refine the measures in collaboration with the Consortium; and that the Consortium should be involved in future implementation efforts. Most importantly, we requested that CMS recognize that the state of the art of physician performance measures is not yet perfect, and while we support the use of measurement to promote quality improvement, we do not support these measurements use for individual accountability, comparison or evaluation of competence. We felt that CMS should involve the National Medical Specialty Societies and Boards in addressing what constitutes the appropriate specialty specific variants in clinical practice and recommended that specialist physicians be included in the DOQ project. We requested that physician participation in the project be the only public recognition given and that it not be used in any sort of ranking or rating system. The CMS staff assured us that they looked at the DOQ as not being a public reporting pilot and was not intended as such. We also recommended that while DOQ is measuring physician performance that this is a good opportunity to come up with a measure of physician productivity. This may help with eliminating CMS's assumption that physicians are able to increase their productivity by 30% every year to keep up with projected decreases in reimbursement. Provider Education Initiatives CMS adopted our suggestions on improvement of provider education initiatives and will continue the paper publications while working for improved electronic communications. EMTALA We were notified that the final rule on EMTALA is not yet published and can be expected in the spring. Coding We heard a report from the Program Integrity Office and requested that the staff continue their efforts to have Medicare contractors make their coverage and coding articles on policies and their "Frequently Asked Questions" available through a data base which is searchable by CPT code in order to make the rules for coding more easily understood by physicians. We learned that it is possible to request a comparative billing report from a contractor and we made a recommendation that when an individual requests that billing report, that request does not trigger an investigation of that individual. PPAC'S Role We discussed initiatives to make PPAC a more effective advisory council, while recognizing that we are only an advisory council. CMS currently sets the agenda of PPAC and we are only allowed to discuss items which are previously published in the Federal Register. We therefore requested that old business be included in some fashion in the Federal Register so that responses from CMS to PPAC could be reviewed and discussed. Tom Grissom of CMS indicated his willingness to consider our issues and place them on the agenda. Feedback It was very helpful during discussions to be able to quote information I had received by e-mails from physicians across the country. Please feel free to give me feedback on the actions that PPAC has taken or what our responses to CMS should be for future issues. Thank you for taking the time in reading this. Sincerely, Barbara L. McAneny, M.D., F.A.C.P.
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