MIPS Could Slow the Move Away From Fee-for-Service Pay, Panel Says

Kerry Dooley Young

March 16, 2018

Medicare's fledgling Merit-based Incentive Payment System (MIPS) would incorporate the same drawbacks of earlier approaches for pegging physician reimbursement to judgments about quality of care, with the potential for large bonuses for certain clinicians eroding the incentive to join more challenging models intended to improve patient care, an influential federal panel said Thursday.

In its March report to Congress, the Medicare Payment Advisory Commission (MedPAC) put forward its full case for ending the fledgling MIPS program. MedPAC argues that MIPS will fail to deliver the desired improvements in quality of care because of flaws in its design, such as a lack of comprehensive measures to assess low-value care.

The panel also suggested that MIPS could inadvertently work against efforts to move more physicians into advanced alternative payment models (A-APMs) by giving them more reason to stick with traditional fee-for-service (FFS) payment. A-APMS are seen as a powerful tool for working to improve the quality of medical care provided to senior citizens and people with disabilities.

"The potential for positive adjustments in MIPS may be so high that staying in FFS appears more attractive for clinicians than moving to A-APMs. This concern is not theoretical," MedPAC wrote in the report, citing results seen with the value modifier (VM) program.

In 2017, 69 practices received VM payment bonuses equivalent to about 77% of their fee schedule revenue, MedPAC noted in the section of the March report laying out its call for the creation of what it calls a voluntary value program for fee-for-service Medicare to replace MIPS. Elsewhere in the report, MedPAC noted that more than 5000 practices received an incentive payment of 46% of their fee schedule revenue.

MedPAC's report likely will become part of the ongoing deliberations about MIPS, which represents a major challenge to many physicians. It's far from clear whether Congress would act on MedPAC's advice on MIPS, a proposal on which there was dissent even among the panelists. Two MedPAC members voted no on the proposal in an earlier meeting.

Lawmakers mandated the creation of MIPS as part of the bipartisan 2015 Medicare Access and CHIP Reauthorization Act (MACRA), a measure to which many members of Congress point to as an example of successful bipartisan compromise.

Need for Fast Action

Still, changes to MIPS seem likely in the future. Members of both parties long have shown a willingness to tweak federal law on Medicare payment for physicians. On March 21 the House Ways and Means Health Subcommittee will hold a hearing on MACRA implementation, with witnesses speaking about MIPS and APMs.

Ways and Means Health Subcommittee Chair Peter Roskam (R-IL) also intends for the hearing to focus on the Trump administration's "priorities in achieving greater value and outcomes in Medicare" through MIPS and APMs, according to a notice for the meeting.

"We now have the opportunity, in a bipartisan manner, to make sure there is clarity and certainty for Medicare doctors while improving care for the beneficiaries they serve," Roskam said in a press release. "I look forward to hearing from the Administration and to a fruitful bipartisan conversation around MACRA and its implementation."

MedPAC Executive Director James E. Mathews, on a Thursday call with reporters, said he hadn't been invited to appear at the Ways and Means hearing, at least as of that time. Still, MedPAC's March report stresses a need for quick action on MIPS, as the program is likely to quickly become entrenched as Medicare policy. Policymakers likely will keep this suggestion in mind, even if planning to keep MIPS in place.

"If history is any guide, once the apparatus for MIPS is established and up and running, the process will have its own momentum, and it will become even more difficult to substantially change or improve the program," MedPAC wrote in the report.

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