Repeal MIPS, Medicare Advisors Say in SGR Deja Vu

October 09, 2017

A group of experts who once urged Congress to repeal Medicare's old method for setting physician compensation wants to repeal most of the system that replaced it this year, declaring it unsustainable.


What might resemble a tremor in the Medicare program breaks down like this:

  • The group of experts is the Medicare Payment Advisory Commission (MedPAC), an independent agency created by Congress in 1997.

  • The old Medicare system for setting fee-for-service (FFS) compensation relied on a so-called sustainable growth rate (SGR) formula, much hated by organized medicine for continually threatening massive pay cuts.

  • What MedPAC now wants to repeal is the Merit-based Incentive Payment System (MIPS), created by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which medical societies largely supported. MIPS is one of two payment tracks created by MACRA, which did away with the SGR formula. Under MIPS, physicians receive bonuses or pay cuts on the basis of how they score on performance measures pertaining to clinical quality, cost-effectiveness, practice improvement, and use of electronic health record systems.

At a MedPAC meeting last week, two of the group's policy analysts ― Kate Bloniarz and David Glass ― made a case for eliminating MIPS that garnered near unanimous agreement from the commissioners, according to Modern Healthcare. Echoing criticisms by organized medicine, Bloniarz and Glass said that the "extremely complex" reporting requirements of MIPS would cost clinicians more than $1 billion this year. For all that work, the performance measures in MIPS won't succeed in identifying physicians who provide high-quality care, in part because physicians can choose the measures they know they can ace.

Bloniarz and Glass proposed replacing MIPS with a "voluntary value system" that would withhold 2% of physicians' FFS payments. Physicians could get the withheld payments back, and then some, however. One way would be to choose the other reimbursement track in MACRA, called Advanced Alternative Payment Models (A-APM). Physicians in A-APMs, which can be a Next Generation Accountable Care Organization or a Track 1 or 2 Shared Savings Program, receive a 5% bonus for assuming more financial risk in patient care.

Another way to get the withheld payments back and earn a bonus in the new plan would be to join a group of other physicians whom the Centers for Medicare & Medicaid Services (CMS) would assess using population-based measures of quality and cost. As opposed to MIPS, physicians wouldn't have to report how they performed. CMS would do the grading on the basis Medicare claims and surveys.

However, if a physician doesn't choose to participate in the new program in either of these two ways, he or she would lose the 2% that was withheld, according to Bloniarz and Glass.

The MedPAC analysts didn't arrive at their plan to replace MIPS overnight. In April, just 4 months into the program's rollout, MedPAC staff told the commission that MIPS was unlikely to succeed and called for radical changes similar to the ones proposed last week. MedPAC, in turn, passed on this dire assessment to Congress in a June report, but didn't make any formal recommendations.

However, a formal recommendation to repeal MIPS now appears in the works. "We really have to get rid of MIPS," Modern Healthcare quoted MedPAC commissioner Rita Redberg, MD, as saying. "No one went into medicine to check all these boxes." Only one of the 17 commissioners was said to have opposed repeal.

Commissioners weren't sold on the proposed replacement for MIPS, however. The 2% withholding payment struck commissioner Craig Samitt, MD, for example, as too small to persuade physicians to change their professional behavior.

Accordingly, MedPAC analysts were charged with fine-tuning their proposal for further consideration. If commissioners adopt it, they will present it to Congress as a formal recommendation sometime next year, according to MedPAC.

A recommendation is just a recommendation, however. MedPAC urged Congress to repeal the SGR formula for physician compensation in 2011. Lawmakers were warm to the idea, but they didn't get around to junking Medicare's notorious math until 2015.

Follow Robert Lowes on Twitter @LowesRobert


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