2011 and Beyond-Quo 2011 and Beyond-Quo VadisVadisJames P. Borgstede, M.D., James P. Borgstede, M.D., FACRFACR

President-ElectPresident-Elect • ABR of the futureABR of the future

• ABMS of the futureABMS of the future

• Integration of ABR within healthcare Integration of ABR within healthcare and healthcare regulatory bodiesand healthcare regulatory bodies

Thanks

• Gary Becker and ABR staff Gary Becker and ABR staff • David Laszakovits David Laszakovits • Jennifer BosmaJennifer Bosma

The ABR of the FutureThe ABR of the Future

• Increased demands to demonstrate Increased demands to demonstrate relevance of certificationrelevance of certification

• Increasing expectations of Increasing expectations of accountability to our diplomatesaccountability to our diplomates– ABR has established advisory ABR has established advisory

committeescommittees

• Increased demands from a more Increased demands from a more robust American Board of Medical robust American Board of Medical Specialties (ABMS)Specialties (ABMS)

ABMS of the FutureABMS of the Future

• More robust More robust • More legislatively More legislatively

active active• Continuous MOC Continuous MOC

rather than 10 year rather than 10 year cyclescycles

• Involvement and Involvement and promotion of promotion of institutional MOCinstitutional MOC

• Significant presence of Significant presence of primary care boards in primary care boards in ABMS governanceABMS governance

• Competition from rogue Competition from rogue organizations for organizations for staturestature

Integration of the ABRIntegration of the ABRwithin healthcare and within healthcare and

healthcare regulatory bodieshealthcare regulatory bodies

• Movement away from concerns for access• Movement away from payment for service

and toward payment for quality•Quality = value X price/ time

• How does this transformation from payment for service to payment for quality occur? Potentially thru Accountable Care Organizations (ACO)?

• An integration of traditional specialty societal economic efforts, e.g. ACR, with future expectations on ABMS member boards, e.g. ABR, as objective verifiers of quality.

• Healthcare continues to increase as percentage of GDP and all payers are looking for ways to save money

• Movement toward improvement in quality, decreasing costs, improving delivery

Socioeconomic TruismsSocioeconomic Truisms

• Primary Care is KingPrimary Care is King• Quality is the coin of the realm (to some)Quality is the coin of the realm (to some)• However, quality is a shill to some payers and However, quality is a shill to some payers and

some in the government.some in the government.• Shill-definition: Somebody (payer) who Shill-definition: Somebody (payer) who

promotes somebody else (quality) or makes a promotes somebody else (quality) or makes a sales pitch (financial incentive to physicians) sales pitch (financial incentive to physicians) for something (better care) for reasons of for something (better care) for reasons of self-interest (payer saves money).self-interest (payer saves money).– Encarta Dictionary North AmericaEncarta Dictionary North America

• There is a fusion of medical economics, There is a fusion of medical economics, quality, safety, and reimbursement which may quality, safety, and reimbursement which may or may not improve patient care.or may not improve patient care.

CertificationMOC

State Medical Licensure

Quality Organizations

Private Not-for-Profits

CertificationMOC

Quality Organizations

Private Not-for-Profits

MOL

An ExampleAn Example

Participation in the Center for Participation in the Center for Medicare and Medicaid Services (CMS) Medicare and Medicaid Services (CMS) Physician Quality Reporting Initiative Physician Quality Reporting Initiative

(PQRS)(PQRS)

The Maintenance of Certification The Maintenance of Certification Program (MOCP) operated by an ABMS Program (MOCP) operated by an ABMS

specialty body for CMSspecialty body for CMS

The ABMS Maintenance of Certification The ABMS Maintenance of Certification (MOC) program requiring practice (MOC) program requiring practice

quality improvement (PQI)quality improvement (PQI)• These are three separate programs:

– PQRS (CMS $ 1% in 2011)– If PQRS then opportunity to participate in

MOCP (CMS $ 0.5%)– PQI as part of ABR MOC separate from $$

• Voluntary program began in 2007Voluntary program began in 2007

• Receive bonus payments of 1% Receive bonus payments of 1% ((previously 1.5 percentpreviously 1.5 percent) of their total ) of their total allowed Medicare charges by allowed Medicare charges by satisfactorily submitting quality satisfactorily submitting quality information for services they furnish information for services they furnish in the calendar year.in the calendar year.

• 17 % of clinicians & 16 % of 17 % of clinicians & 16 % of radiologists that could participate in radiologists that could participate in PQRS reporting did so in 2009.PQRS reporting did so in 2009.

• CMS failed to reimburse the promised 1% in many cases.

The Physician Quality Reporting The Physician Quality Reporting Initiative (PQRS)Initiative (PQRS)

• Physician Consortium on Performance Physician Consortium on Performance Improvement (PCPI). AMA sponsored.Improvement (PCPI). AMA sponsored.– The PCPI is a physician-led measure The PCPI is a physician-led measure

developerdeveloper. .

– They do not implement their measures but They do not implement their measures but make them available for use by any payer or make them available for use by any payer or organization that wishes to use them, e.g. organization that wishes to use them, e.g. CMS primarily. Other payers have also used CMS primarily. Other payers have also used PCPI measures. PCPI measures.

– Most of the measures in the current PQRS Most of the measures in the current PQRS program were developed through the PCPI. program were developed through the PCPI.

– PCPI is now working with ABMS and specialty PCPI is now working with ABMS and specialty boards/societies to develop measures that can boards/societies to develop measures that can

be used for be used for PQI PQI projects to meet MOC projects to meet MOC requirements in general and to help meet the requirements in general and to help meet the PQRS MOCP requirements.PQRS MOCP requirements.

• The Secretary of HHS will establish a The Secretary of HHS will establish a composite of appropriate, risk-based composite of appropriate, risk-based measures of quality that reflect the health measures of quality that reflect the health outcomes and health status of Medicare outcomes and health status of Medicare beneficiaries. beneficiaries.

• The Secretary of HHS must seek The Secretary of HHS must seek endorsement of the quality measures by the endorsement of the quality measures by the entity with a contract with the Secretary entity with a contract with the Secretary under section 1890(a) [e.g., the National under section 1890(a) [e.g., the National Quality Forum].Quality Forum].

• The Physician Consortium on Performance The Physician Consortium on Performance Improvement (PCPI) seeks to develop the Improvement (PCPI) seeks to develop the measures that NQF will endorse.measures that NQF will endorse.

• ACA authorizes PQRS payment ACA authorizes PQRS payment incentives/adjustments:incentives/adjustments:

• 2011: 1% incentive 2011: 1% incentive • 2012-2014: 0.5% incentive 2012-2014: 0.5% incentive • 2015: 98.5% payment adjustment of fee 2015: 98.5% payment adjustment of fee

schedule (1.5% penalty for not reporting schedule (1.5% penalty for not reporting satisfactorily)satisfactorily)

• 2016 and on: 98% payment adjustment2016 and on: 98% payment adjustment• If an individual radiologist billed Medicare If an individual radiologist billed Medicare

$200,000 in one year, the PQRS incentive would $200,000 in one year, the PQRS incentive would give them $2000 for PQRS.give them $2000 for PQRS.

• Assuming CMS reimburses! Assuming CMS reimburses!

Incentive Payments for Incentive Payments for Physician Quality Reporting Physician Quality Reporting

System (PQRS)System (PQRS)

Reporting MeasuresReporting Measures

Reporting MechanismsReporting Mechanisms

• Claims based-used in past but may Claims based-used in past but may change to make participation more change to make participation more “facile”.“facile”.

• CMS is moving toward a data CMS is moving toward a data registry based participation.registry based participation.– Radiology needs eligible registriesRadiology needs eligible registries– Establishing an eligible registry is Establishing an eligible registry is

challenging. ACR is developing challenging. ACR is developing registries in radiology. registries in radiology.

What about MOCP?

• Section 3002 of the Affordable Care Act (ACA) requires an option for a physician to provide CMS with data on quality measures through a Maintenance of Certification Program (MOCP) operated by an ABMS specialty body.

• The statute authorizes an additional incentive of 0.5 percent for 2011 – 2014, when requirements are met.

• Beyond 2014, participation in MOCP and successful completion of a MOCP practice assessment may be incorporated into the “composite of measures” of quality furnished under the physician fee schedule value-based payment modifier.

An individual billing Medicare $200,000 in one year would receive an additional $2000 for participation. Individuals will not participate for a total of $2000 + $1000The significance is not the incentive but instead allowed participation

MOCP MechanicsMOCP Mechanics• ABMS board e.g. ABR has applied for approval from ABMS board e.g. ABR has applied for approval from

CMS as the “submitter of data” for ABR diplomates CMS as the “submitter of data” for ABR diplomates to fulfill both part 4 of MOC for ABR recertification to fulfill both part 4 of MOC for ABR recertification and qualification for MOCP reimbursement under and qualification for MOCP reimbursement under the ACA.the ACA.

• If approval is finalized, ABR MOC participants would If approval is finalized, ABR MOC participants would then be eligible for the additional 0.5% incentive IF:then be eligible for the additional 0.5% incentive IF:– They have met the PQRS requirementsThey have met the PQRS requirements– They have “successfully completed a qualified They have “successfully completed a qualified

MOC Program practice assessment for 2011”MOC Program practice assessment for 2011”• This is the only pathway by which the MOC PQRS This is the only pathway by which the MOC PQRS

incentive may be obtained.incentive may be obtained.• ABMS could establish the umbrella program for all ABMS could establish the umbrella program for all

ABMS boards to qualify for both MOC part 4 ABMS boards to qualify for both MOC part 4 fulfillment and MOCP reimbursement under the fulfillment and MOCP reimbursement under the ACAACA

“To serve patients, the public, and the medical profession. . .”

“. . .by certifying that its diplomates have acquired, demonstrated, and maintained a requisite standard of knowledge, skill, and understanding. . .”