For the third year in a row, pay for performance (P4P) dominated debate at
the annual policymaking meeting of the AMA's House of Delegates in Chicago
The AMA delegates have grown increasingly alarmed about the expansion of
pay-for-performance programs in the public and private sectors, especially as
many of the programs have failed to abide by principles of quality that were
written by the house during its 2005 annual meeting (Psychiatric
News, July 15, 2005).
The growing stridency of physician opposition to P4P was reflected in the"
Take Back Our Profession" campaign waged by a number of delegates
wearing badges with that motto printed on it—a reference to the call by
AMA President William Plested, M.D., last year for physicians to "take
medicine back" from third-party payers and government regulators.
But as in past years, opinion in the house was divided between the most
ardent delegates—some of whom supported resolutions calling for the
immediate cessation of all P4P programs and an end to physician participation
in those programs—and others who argued that the AMA could not afford to
appear to be against quality and had to allow room for AMA lobbyists to
negotiate with the government and private payers.
At the end of nearly five hours of debate, delegates approved an
extensively amended and edited an AMA board report on P4P that calls for the
organization to "collaborate with interested parties to develop quality
initiatives that exclusively benefit patients, protect patient access, do not
contain requirements that permit third-party interference in the
patient-physician relationship," and are consistent with the AMA's
Among the delegates' additions was a recommendation that the "AMA
actively oppose any pay-for-performance program that does not meet all the
principles" approved in 2005.
"The AMA has very good principles on P4P," John McIntyre, M.D.,
chair of the Section Council on Psychiatry, told Psychiatric News."
The problem is that no one is following them, so what the house has
said is that we have to take a stronger position that we will work
aggressively to defeat plans that do not follow the AMA principles. And the
AMA is taking a clearer stand that physicians should be the ones to drive the
entire quality debate, rather than being reactive to plans that the government
and insurance companies put out."
But reflective of the tactical divisions in the house was a lengthy debate
about whether the recommendation on opposition to programs that don't meet AMA
principles should also include opposition to programs that don't meet the
specific guidelines also approved by the house in 2005.
While the "principles" are a set of five broad, overarching
rules by which P4P should be governed, the guidelines are a more detailed set
of recommendations for the structure and organization of P4P programs.
Board members such as cardiologist James Rohack, M.D., argued successfully
that to demand the organization oppose any program that did not follow the
letter of all its guidelines would almost certainly bar physicians from
participation in any plan and tie the hands of organized medicine in
negotiations with the government and private payers whose plans were not
ideal, but might be reasonably acceptable.
Testimony on P4P during reference committee hearings, prior to the
convening of the full house, was heated.
"Pay for performance is a gimmick to disguise economic profiling and
rationing of health care for profit," said Peter Levine, M.D., of the
District of Columbia delegation. "It is bad for doctors, bad for
patients, and it needs to go away. The big-brother approach to medicine is
going to result in cherry picking of patients, and it is going to be
disadvantageous to minority and poor patients."
Representing those urging a different approach was Richard Peer, M.D., a
delegate from New York. "Can you imagine the publicity if the AMA
changes course and walks away from pay for performance?" Peer asked."
The press may well say that doctors aren't interested in performance;
they are only interested in their bottom line.
"It is critical that we be at the table," Peer said, echoing
the standard rhetorical motif about the need to have a hand in negotiations
with the government and payers.
Stephen Permut, M.D., of Delaware, chair of the AMA's Council on
Legislation, emphasized the AMA's efforts in other political
areas—especially reforming the Medicare payment formula and its much
opposed sustainable growth rate (SGR) component, which ensures that as volumes
increase in the Medicare program, reimbursement to doctors goes down.
He said success in those areas was dependent on the willingness of
organized medicine to participate in quality-improvement programs.
"Our patients are at great risk of losing their physicians if the SGR
and Medicare payment reform is not accomplished," Permut told delegates
in the reference committee hearing. "Unfortunately, we cannot move those
principles forward unless we are willing to talk about pay for
On the subject of the SGR, delegates approved a report recommending that
the AMA "pursue enactment of legislation that provides for at least two
years of positive updates that accurately reflect the increases in costs of
caring for Medicare beneficiaries and lays the groundwork for complete repeal
in the near future, and that the AMA's ultimate goal continue to be complete
repeal of SGR and its replacement with a fair and equitable payment system
that adequately reflects increases in the cost of caring for Medicare
In related business, the delegates approved a resolution denouncing the
government's provision of subsidies to Medicare Advantage plans.
The resolution calls on the AMA to "seek to have all subsidies to
private plans offering alternative coverage to Medicare beneficiaries
eliminated" and urges that "these private Medicare plans compete
with traditional Medicare fee-for-service plans on a financially neutral basis
and have accountability to the Centers for Medicare and Medicaid Services, and
that any savings from the elimination of subsidies to private plans be used to
address the sustainable growth rate."
The House of Delegates action on government subsidies to private, managed
care Medicare plans came just two days before AMA trustee Robert Wah, M.D.,
testified to the House of Representative's Budget Committee on the subject
(see AMA Wants Medicare Imbalance Fixed)).
Finally, the delegates also adopted a policy stating that declarations of
apology by physicians, confessions of regret, or admission of errors to
patients or family members following a less-than-favorable treatment outcome
be inadmissible as evidence in liability lawsuits.
Twenty-eight states have "I'm sorry" laws that make physicians'
statements of regret inadmissible.
The policy was over whelmingly supported by the AMA delegates, who
emphasized that an expression of regret following a poor outcome was essential
in a good physician-patient relationship and that the strength of that
relationship was the best protection against litigation.
The reports and resolutions approved by the AMA House of Delegates
are posted at<www.ama-assn.org/ama/pub/category/17714.html>.
The report of the AMA board on pay for performance is posted at<www.ama-assn.org/ama/pub/category/17616.html>.▪