May 25, 2007

STATEMENT OF SENATOR BENJAMIN L. CARDIN ON THE VOLUNTARY MEDICARE QUALITY REPORTING ACT OF 2007

Mr. President, today I rise to introduce the Voluntary Medicare Quality Reporting Act of 2007. I thank my good friend, the gentleman from Pennsylvania, Mr. Specter, for joining me in this effort. This is an important bill for tens of millions of Medicare beneficiaries, for the physicians, nurse practitioners and allied health professionals who treat them, and for the future of the Medicare program.

At the end of this year, providers will again face the prospect of an across-theĀ¬board cut in their Medicare reimbursements. The scheduled cut for 2008 is the largest ever-9.9 percent. These cuts are the result of a flawed reimbursement system created in 1997 that uses the Sustainable Growth Rate formula, or SGR, to determine an acceptable increase in the growth of provider expenditures.

Medicare reimbursements increase when the previous year's payments do not exceed a target level that is based on the growth of our economy. However, when the previous year's payments exceed that target level, reimbursements are cut. According to MedPAC, the SGR formula would reduce Medicare provider reimbursements by 40% over the next eight years if Congress does not act. MedPAC is also concerned that over the next several years these reductions "would threaten beneficiary access to physician services over time, particularly those provided by primary care physicians." MedPAC recognizes the importance of provider participation in the Medicare program, particularly in our rural and underserved urban areas where the decision to not accept new Medicare patients can make all the difference in seniors' access to medical care.

Congress recognizes this as well, and so we have intervened to prevent scheduled cuts resulting from SGR from taking effect. For all except the newest members of this body, this process of enacting a "physician fix" is a familiar scenario. For the past four years, Congress has acted to prevent these cuts to providers, usually through a last-minute provision added to a must-pass bill.

In the I09lh Congress, J introduced bipartisan legislation implementing MedPAC's recommendations and calling for Congress to repeal the SGR formula and update provider reimbursements by the cost of care. Replacing SGR will require a thoughtful and protracted process involving the input of lawmakers and the provider community, and it is costly, but it is something that we must do.

The most recent "fix" was made to the 2006 Tax Relief and Health Care Act, P.L. 109-432. That law froze payment rates, staving ofT an across-the-board cut of 5.1% percent. Congress also added a quality reporting system called the Physician Quality Reporting Initiative program (PQRJ), which made providers eligible for a bonus payment of 1.5 percent of their total allowed Medicare charges if they report to HHS on certain quality measures starting in July 2007.

This new system is also known as "pay-for-reporting,' and it is based on the concept that physicians should receive an increase in Medicare reimbursement only once they have participated in extensive quality reporting. Across my state. I have heard serious concerns that this will lead to a mandatory reporting system in the near future. and that we will soon see an untested "p ay-for-performance" system in place.

Now, I think all my colleagues would agree that our seniors deserve the highest quality care. But in our quest for improved quality. we must answer two questions here: should proceed with an untested system of reporting requirements just for the sake of reporting. and will we actually achieve better care for our seniors via the PQRI.

I am very concerned about implementing reporting requirements that have not been tested. J believe that we must have the right process in place for defining a quality reporting system for services provided to Medicare beneficiaries by health care professionals. We should not be establishing reporting requirements for health professionals just for the sake of reporting. and we should not be moving forward with this system until we have adequate time to evaluate each stage of its development.

Current law does not provide sufficient time to assess the appropriateness and effectiveness of this new system. Nor do they take into account the fact that most physicians and other health professionals have no experience in quality reporting and do not have in place the necessary health infonnation technology and administrative infrastructures to participate in a reporting system.

The bill I am introducing today will assure that health professionals will be at the center of the process for defining areas where quality measures are needed. as well as for defining the relevant measures themselves. Why is this important? Health professionals must be actively engaged in developing and implementing an effective reporting system because they are on the front lines of health care delivery, and they best understand the nexus between care delivery and quality measurement. The development process for quality measures must be transparent and consistent for all health professionals because they are the ones who will determine its successful implementation.

Additionally, quality measures should be tested across a variety of specialties and practice settings before they are included in a reporting system because measures must be clinically valid to be relevant for defining quality, and because physicians and health professionals practice in a variety of settings, for example: small vs. large practices, urban vs, suburban vs. rural locations, office-based vs. hospitalabase practices.

Most importantly, we should not be using hastily devised quality measures to justify reimbursement cuts. There are some who advocate pay-for-performance as a way to slow the growth of physician spending. They think we can accomplish lower physician expenditures by setting arbitrary standards and then cutting payments to physicians who fail to meet them. But across America, there are practices that would face tremendous obstacles in meeting such standards: they lack of the information technology necessary to document and report standards in a timely manner; they see patients with economic and language barriers that will result in higher noncompliance rates; they treat a patient population for whom ethnic and racial differences require different clinical interventions than for other patients. Ignoring these considerations will not only fail to dramatically improve quality, it will significantly penalize providers who treat traditionally underserved populations.

This bill provides an opportunity to thoughtfully and carefully develop effective quality measures that reflect differences in practice patterns, to share our findings. and to determine and encourage the most cost-effective methods of providing the highest quality care.

Rather than moving forward precipitously in 2008 with a permanent Medicare quality reporting system after a transitional 6-month period this year, as current law requires, our bill, the Voluntary Medicare Quality Reporting Act of 2007, instead would establish a more realistic timeline for quality measure reporting by health professionals. It does so by:

  • requiring the Secretary first to evaluate the 6-month transitional reporting system and reporting findings to the Congress by June I, 2008;
  • requiring the Secretary to undertake demonstrations for defining appropriate mechanisms whereby health professionals may provide data on quality measures to the Secretary through an appropriate medical registry;
  • allowing physicians and other eligible professionals to continue reporting to the Secretary quality measures developed for 2007, in order for the Secretary to refine systems for reporting quality measures;
  • after completion of the evaluation. phasing in a permanent Voluntary Medicare Quality Reporting Program, with implementation beginning January 1, 2010, based on a consistent set ofrules that define an orderly and transparent process of quality measure development;
  • requiring that the Physician Consortium for Performance Improvement of the American Medical Association be the beginning point for the designation of clinical areas where quality measures are needed;
  • having the Consortium. in collaboration with physician specialty organizations and other eligible professional organizations, develop and propose quality measures to a consensus organization (such as the National Quality Forum) for endorsement; and
  • prohibiting the Secretary from using any measures that have not been recommended by the Consortium and endorsed by the consensus organization.
I am confident that with all of these measures we will achieve a successful and effective quality reporting system that will truly make a difference in the quality of care that our Medicare beneficiaries receive. At the end of this year. as Congress moves forward to address the physician reimbursement issue. I urge my colleagues to support this rational approach to promoting quality and guaranteeing access to care.