CMS Should Quickly Test Alternative to MIPS, Expert Says

Kerry Dooley Young

March 06, 2018

A leading Washington health expert is urging Medicare to quickly test an alternative approach to its fledgling Merit-based Incentive Payment System (MIPS) for physicians, while also pressing for the creation of a targeted reimbursement metrics that both the federal healthcare giant and private insurers would use.

In an article published online February 28 in the New England Journal of Medicine, Gail Wilensky, PhD, a former adviser to President George H. W. Bush and the administrator from 1990 to 1992 of what is now the Centers for Medicare & Medicaid Services (CMS), offered proposals to aid physicians who face a daunting challenge in adapting to MIPS, even as some healthcare policy experts lambaste the design of the program.

This month, the influential Medicare Payment Advisory Commission (MedPAC), which Wilensky chaired from 1997 to 2001, will send Congress a formal recommendation to scrap MIPS and start over with a new approach to Medicare physician pay. This MedPAC recommendation comes as many physicians struggle with rafts of competing metrics demanded by private insurers, Wilensky observes.

"The proliferation of quality measures is imposing substantial burdens on clinicians, and many of these measures are regarded as poor proxies for quality or as not reflecting what is important to patients," writes Wilensky, who is also a senior fellow at Project HOPE.

CMS should work with representatives of commercial insurers and groups representing clinicians and consumers to develop "a small set of metrics that better reflect outcomes and that matter to patients," she writes.

"All payers could then be encouraged to use this reduced set of metrics," Wilensky says.

Pragmatic Approach?

Wilensky offers a pragmatic Washington insider's approach to MedPAC's recommendation on scuppering MIPS, cardiologist Rita Redberg, MD, current editor of JAMA Internal Medicine, told Medscape Medical News.

A current MedPAC member, Redberg strongly advocated for the panel's recommendation for replacing MIPS with a voluntary system for judging physician care. In January, MedPAC voted 14-2 in favor of adding this proposal to its March report to Congress, which is expected to be released in the middle of the month.

But implementing MedPAC's new approach would require Congress to revisit decisions made in its 2015 overhaul of Medicare's physician pay. In her article, Wilensky spells out how the looming 2018 midterm election and the sharply divided Senate make it unlikely that Congress could soon pass another major health law. Wilensky also urges CMS to use its existing in-house resources to advance MedPAC's idea, an approach Redberg applauded.

"She's coming at it from the point of view of what can actually happen. Our recommendation would require congressional action," Redberg said. "As she pointed out very practically, that's unlikely to happen this year."

CMS could use its Center for Medicare & Medicaid Innovation (CMMI) to test MedPAC's proposal, Wilensky writes. The center, created as part of the 2010 Affordable Care Act, has authority to test different approaches for improving the delivery of healthcare. MedPAC's proposal calls for a 2% withholding of Medicare fee-for-service payments. Physicians could regain this money through two paths under the MedPAC model. They could participate in an advanced alternative payment system (APM), which would require that they accept financial risk, or join a real or virtual group that would be evaluated by population-level measures, such as readmission rates.

A CMMI "pilot program would provide real-world evidence as to whether this strategy is an improvement over the MIPS in terms of helping clinicians improve their practice and helping beneficiaries identify the health care organizations that offer better outcomes for their needs," Wilensky writes.

She also suggests that CMMI test a primary care APM that has been proposed by the American Academy of Family Physicians. Large medical trade groups, including the American Hospital Association, have asked that CMS revise MIPS but not end it. The American Medical Association would like Congress to allow CMS to slow down the full phase-in of MIPS in 2019, Wilensky notes. In closing her article, she calls on physicians to reach out to their professional associations and lawmakers to reshape rules of quality metrics.

"In the past, practicing clinicians have been woefully bad at making their voices heard," Wilensky writes. "Now is a good time for that to change."

Dr Wilensky has disclosed no relevant financial relationships.

N Engl J Med. Published online February 28, 2018. Full text

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