MedPAC Presentation Questions the Premise of MIPS

Ken Terry

April 24, 2017

The Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare's reimbursement policies, is considering whether to take a hard line against the Merit-Based Incentive Payment System (MIPS). A staff presentation last month and the ensuing discussion by the 17 MedPAC members indicated that the commission sees some serious problems with the program, which began January 1.

The MedPAC staff recommended making some radical changes in MIPS and in the Advanced Alternative Payment Model (AAPM) program, the alternative track in the Quality Payment Program authorized by the Medicare Access and CHIP Reauthorization Act (MACRA). AAPMs include certain accountable care organizations (ACOs), patient-centered medical homes, and bundled-payment arrangements.

MedPAC's concerns about MIPS may be included in its annual June report to Congress, said Paul Ginsburg, PhD, a MedPAC member and a professor of public policy at the Schaeffer Center for Health Policy and Economics at the University of Southern California, Los Angeles, in an interview with Medscape Medical News. However, because the commission did not consider in depth or vote on the staff proposal, MedPAC will probably not make any recommendations to Congress in June, he said. The commission is more likely to move on that next year, he added.

"Unlikely to Succeed"

In the March presentation, the MedPAC staff said, "MIPS is unlikely to succeed at identifying or paying for clinicians delivering value to the [Medicare] program, at great administrative burden."

The problems with MIPS, the staff said, include the following:

  • The large number of quality measures, many of which most doctors already excel on or are narrowly targeted to specific specialties;

  • The lack of comparability of scores across clinicians because the clinicians are allowed to choose their own measures;

  • Electronic health record  meaningful use and practice improvement data elements that have not been shown to correspond with high-value care; and

  • The relatively small numbers of cases for individual clinicians, which reduce the accuracy of quality scores.

The latter issue first emerged around 15 years ago, when commercial health plans introduced pay-for-performance (P4P) programs that evaluated doctors on quality and cost. If a physician had fewer than about 30 patients with a certain condition, P4P critics argued, the doctor could not be measured fairly on a measure related to that condition. Although MIPS includes elements that go beyond quality and cost, it is clearly a successor to these commercial programs, which did not work very well in the private sector, noted Dr Ginsburg.

The Centers for Medicare & Medicaid Services (CMS) also made a mistake in not providing enough opportunities for physicians to qualify for AAPM bonuses, he said. This is especially true for specialists, he added. ACOs don't feel they need specialists, unless they're in fields like cardiology that coordinate closely with primary care, and CMS's bundled payment programs concentrate on just a few specialties, Dr Ginsburg pointed out.

The MedPAC staff recommended that CMS eliminate performance reporting by clinicians under MIPS and use CMS claims data and patient experience reports instead. To address the sample-size issue, they suggested measuring performance at an aggregate rather than an individual level. That would require physicians subject to MIPS to migrate to the AAPM track, join one of the "virtual groups" that are already on the CMS roadmap, or elect to be measured in a CMS-defined referral area. They could also choose "none of the above" and be assessed a penalty. For those in groups, payment adjustments would be calculated for the entire group.

Under the MedPAC staff proposal to reform MIPS, clinicians would receive greater incentives to join AAPMs than they have today: for example, they would have a larger upside than a downside in a financial risk arrangement that met the criteria for an AAPM. About $500 million that CMS has allotted for payments to exceptional performers under MIPS would be moved into the AAPM track to pay for this additional bonus opportunity.

The staff also proposed a system of "partial capitation" that would give upfront payments to primary care physicians in risk-taking ACOs, to be financed by reducing their fee-for-service reimbursement. A similar approach is used in CMS's Comprehensive Primary Care Plus program for patient-centered medical homes.

Dr Ginsburg said he is "intrigued" by these ideas, and he got the impression that his MedPAC colleagues were also receptive to them. Congress might also be willing to entertain changes in the program, he said. "There's a recognition in Congress that MACRA has not lived up to their goals too well," he noted.

Supporting his contention, a group of 18 Republican congressmen — the so-called Doctors Caucus — called for significant changes in MACRA last October. The Doctors Caucus's letter to CMS and the Office of Management and Budget said that MIPS required practices to report on too many measures for too many patients, that the volume thresholds for MIPS participation should be raised, and that the reporting period should be reduced from a full year to 90 days. Subsequently, the thresholds were raised, but the reporting period has not been decreased.

Reducing Complexity

In an interview with Medscape Medical News, Janet Marchibroda, director of health innovation for the Bipartisan Policy Center in Washington, DC, cited this letter as evidence that some in Congress are dissatisfied with the direction of MACRA regulations. In addition, while Health and Human Services Secretary Tom Price voted for MACRA when he was in Congress, Marchibroda noted, "Secretary Price has been on record saying that he wants to implement MACRA in a way that's easy to understand, minimizes burdens, and is fair to all providers.

"I think the Congress and the administration would be open to and supportive of changes that would reduce complexity, reduce burden, and provide regulatory reform without greatly increasing costs," she said. "In principle, there would be receptivity to MedPac recommendations that would achieve those goals."

Organized medicine has generally supported MACRA. But there have been some rumblings of discontent. Last month, the Medical Group Management Association  complained that CMS had failed to notify clinicians and group practices regarding which physicians qualified for the low-volume threshold exemptions that it had promised in October. There have also been concerns that the 2015 edition EHRs that are required for MIPS reporting next year may not be ready by then.

Meanwhile, a new RAND report estimates that MACRA will reduce physician income between $35 billion and $106 billion over 15 years. Depending on which end of the estimate comes closer to reality, this may not endear MACRA to physicians.

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