Medicare Advisers Urge Quick Action on MIPS Replacement Plan

Kerry Dooley Young

December 07, 2017

WASHINGTON, DC — The members and staff of an influential federal advisory panel pressed today for congressional action to replace the Merit-based Incentive Payment System (MIPS), which is still in the early stages of implementation.

Members of the Medicare Payment Advisory Commission (MedPAC) are honing a proposal to replace MIPS for physicians with a voluntary value program instead.  Panelists and staff described MIPS as an inequitable system in which some practices could see substantial gains while others would see their Medicare pay erode. 

The Centers for Medicare & Medicaid Services (CMS) already has delayed certain MIPS requirements in deference to physicians' concerns. But practices that are well prepared for MIPS could begin to see financial gains from it in 2019, which would make it difficult for CMS and Congress to do away with the program in the future, said Kate Bloniarz, a senior analyst with MedPAC.

"We need to act on this now," Bloniarz told MedPAC members at today's presentation, held here. "The longer the payments go out, the more there will be an established constituency of clinicians receiving very high payment adjustments who will resist any changes to the program."

MedPAC members generally spoke today in support of the staff's voluntary value proposal and the need to replace MIPS. In January the panel will vote on the MIPS proposal as part of a formal package of recommendations regarding future Medicare payment. These recommendations will be presented in March in an annual report to Congress. CMS and lawmakers rely heavily on MedPAC's work in setting payment policies. Payments to doctors and other health professionals cost Medicare's fee-for-service program about $69.9 billion last year.

Congress and CMS have wrestled for decades with approaches to controlling growth of Medicare reimbursement for physicians. Lawmakers in the 1990s attempted to control the growing cost of doctors' pay with a method known as the sustainable growth rate (SGR). Congress acted multiples times to stop the SGR from cutting Medicare payments for doctors before finally scrapping it through the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. MACRA called for alternative payment models (APMs), meant to spur greater coordination and improve patient care. The law also mandated MIPS, which would serve doctors not participating in APMs.

"Bad Pay-for-Performance Hall of Fame"

In June MedPAC warned lawmakers that the current MIPS approach is "unlikely to succeed" because the system of metrics being considered wouldn't achieve the chief aim of pegging reimbursement to quality of care. Medicare payments could be shaved by 9% within a few years for physicians judged not to meet certain standards, MedPAC noted in the June report. Bloniarz pointed out that these payment reductions would prompt calls for relief from MIPS, bolstering arguments for quick action.

 MedPAC panelist Brian DeBusk, PhD, agreed that CMS needs to "get ahead of this early."

"You actually are going to see a lot of constituencies coming to us wanting MIPS" reforms, said Dr DeBusk, who also is the chief executive officer of DeRoyal Industries in Powell, Tennessee, which sells medical equipment.

The MIPS replacement proposal from MedPAC staff would encourage doctors to join or form groups and increase their awareness of the measures, with an intent to ease the reporting burden on individual doctors. CMS has estimated a burden on physicians of $800 million to $1 billion for MIP compliance. While MIPS would be phased out, more advanced alternative payment models created by MACRA would remain in place.

The  proposal detailed by MedPAC staff would let doctors choose to be measured as part of a group and then they could qualify for extra payments based on their performance, as judged through a set group of measures. These costs would be balanced by reductions in pay for other physicians. This approach would free up about $500 million a year that's now intended for MIPS bonuses, according to a MedPAC analysis.

MedPAC member Alice Coombs, MD, expressed some qualms about abandoning MIPS, seeing a value in the measures that check whether certain steps have been performed. While these so-called process measures used in MIPS could be improved, this approach makes a difference at the "grassroots" level of care, said Dr Coombs, a critical care specialist and anesthesiologist at Milton Hospital and South Shore Hospital in Weymouth, Massachusetts.

MedPAC members in general, though, said they were anxious to see the end of MIPS and have CMS work on a replacement set of metrics that perhaps could be adopted by other health organizations. David C. Grabowski, PhD, said he'd put MIPS in the "Bad Pay-for-Performance Hall of Fame," calling it burdensome, complex, inequitable, and arbitrary.

"Most important, it doesn't target and encourage high-value services. We've time and time again moved forward with pay-for-performance systems that have actually, I think, pushed us back as a healthcare system," said Dr Grabowski, who is a professor of healthcare policy at Harvard Medical School in Boston, Massachusetts. "This is an opportunity to repeal the MIPS and think about a program that would actually push us forward."

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