Professional Point

Last October, I wrote about the marketplace trend of "pay-for-performance." This is an effort by payers to realign incentives in health-care services delivery to provide incentives for quality improvement. Started primarily in the private sector, these programs attempt to determine how well health professionals care for their patients and to reward the ones who do best, usually with bonus payments of some sort. There is much variability in these programs as to whether they are pay for performance, for outcomes, for quality improvement or for simply reporting certain outcome measures. The jury is still out on how well these programs accomplish their goals.

Now the public sector is beginning to follow suit. As mandated under the Tax Relief and Health Care Act of 2006, the Centers for Medicare and Medicaid Services (CMS) is implementing a new quality reporting program called the "Physician Quality Reporting Initiative" (PQRI). The PQRI allows eligible health-care professionals-including psychologists-to voluntarily report data on certain established so-called quality measures for services covered by Medicare, and to receive a bonus payment of up to 1.5 percent in return. For the initial reporting period from July 1 through Dec. 31, 2007, the new law requires CMS to use an earlier demonstration version of the program. In other words, no new measures for reporting can be created until 2008.

To be eligible for the PQRI in 2008, new measures must be developed using a process whereby multiple organizations are involved in reaching consensus on the inclusion of specific measures. They must be adopted or endorsed by a consensus-based organization such as the National Quality Forum, which is made up of a broad range of groups including health professional and consumer organizations, employers, public and private sector health insurers, and organizations involved in health-care research. CMS will post a proposed set of measures in August for public comment and will release the final set of measures for 2008 in November. APA's Practice Directorate is engaged in continuing efforts to assure that any measures applied to psychological services are appropriate.

In the meantime, it is the measures being used for the 2007 reporting period that present an immediate problem. In a nutshell, Medicare has been directed to expand its reporting program beyond just physicians, but can use only those measures that were previously used for physicians. The result, then, is confusion-at best-as to whether health professionals other than physicians have access to any measures that are relevant to the services they provide. At worst, CMS is making available a 1.5 percent bonus payment that cannot be accessed currently by psychologists, or other non-physician health-care professionals.

According to the new law, all specialty societies, such as APA, are prevented from introducing any new measures in 2007. The existing list of measures being mandated for the July-to-December reporting period is small-only 74 measures-and only one involves mental health. To make matters worse, that one mental health measure focuses on the use of medications for depression. Because the new Medicare law allows some limited modification of the existing measures, the Practice Directorate sought to modify the one mental health measure on depression to allow the use of psychotherapy to be reported as an alternative to treatment with medication. Unfortunately, our request was denied on the grounds that such a change was believed to fundamentally alter the measure, rather than simply being a minor modification. We have been informed, however, that the existing measure can be used by psychologists consistent with the PQRI if the psychologists are "monitoring the progress of a patient on antidepressant medication while performing a diagnostic interview or providing psychotherapy."

Before making any recommendations about using this measure, the Practice Directorate is pursuing further clarification. We want to better understand what this instruction actually means, and what the implications are of reporting a measure that only recognizes medication as a treatment for depression. It is also important to know that APA, along with a number of non-physicians organizations, attempted to meet with CMS before the law was enacted to discuss the issue of measures for use by non-physicians. Two meetings were scheduled, but CMS canceled both. The agency's position has been that it is simply following the direction of the statute and has little latitude in the matter.

We will provide more information as we obtain it. CMS is reportedly working on educational materials for providers that will be posted online at