AMA: Delegates Want Principles First with Pay for Performance

CHICAGO, June 27 -- The American Medical Association wants third-party payers to put the brakes on pay-for-performance initiatives until there is evidence that such plans benefit patients.

Moreover, after five hours of debate -- often over the addition or deletion of a single word -- the AMA's House of Delegates said that it will "actively oppose" any pay for performance programs that do not meet the AMA's five pay-for-performance principles.

Adopted in 2005, those principles specify that programs should ensure quality of care, foster the patient/physician relationship, offer voluntary physician participation, use accurate data and fair reporting, and provide fair and equitable program incentives.

The number of pay-for-performance programs, which provide monetary bonuses to participating physicians who make progress in achieving specific quality or efficiency benchmarks, has increased significantly over the last four years -- from 35 plans in 2003, to 130, for a growth rate of 271%, according to one report. By 2008, it's estimated that there will be more than 160 pay-for-performance programs covering services provided to an estimated 85 million patients.

J. James Rohack, M.D., a cardiologist from Temple, Texas, and a member of the AMA board of trustees, said the House action authorizes the organization to actively oppose plans that violate the AMA's principles even if the plans are endorsed by individual state medical societies.

The association was already on record as opposing plans that didn't meet AMA criteria, but, said Dr. Rohack, by adding the word "actively" the delegates authorized the AMA to mount opposition against any plan, anywhere that did not meet the standards.

Typically, the national organization does not interfere in state issues unless invited to do so by the state society.

Dr. Rohack said the delegates' decision to ignore that tradition signals their frustration with the way in which pay for performance is being implemented by private insurers and concern that the Centers for Medicare and Medicaid Services (CMS) will also "use pay for performance to cut costs rather than improve quality."

Meanwhile, Dr. Rohack, speaking for the board of trustees during the House debate, repeatedly urged the delegates to refrain from putting too many limits on what the AMA leadership could do in attempting to negotiate pay-for-performance plans with payers.

Too many restrictions, he said, would mean that the AMA would "lose our seat at the table" during crucial negotiations with CMS, which is on track to fix its flawed sustainable growth rate (SGR) physician payment formula by switching to a pay for performance model.

"We don't want a seat at the table," responded, Marcy Zwelling, M.D., a delegate from Los Alimitos, Calif. "We want to stand on the table."

Among the restrictions considered, debated, and ultimately defeated by a vote of 311 to 209 was the suggestion that the AMA oppose any plan that included financial incentives-a key element of pay for performance.

The delegates also instructed the AMA leadership to collect data on the efficacy of pay for performance, including data on special populations that may have increased health risks.

The delegates also pledged the AMA to "an unshakable and uncompromising commitment to the welfare of our patients and the health of our nation and the primacy of the patient-physician relationship, free from intrusion by third parties."