Many MIPS Measures Not Valid, ACP Finds

Kerry Dooley Young

April 23, 2018

An analysis performed by an influential physicians' group found that many components of Medicare's Merit-based Incentive Payment System (MIPS) fall short of the goal of improving patient care, with some of these metrics even raising potential risks for older patients.

This new research from the American College of Physicians (ACP) may bolster the arguments of MIPS critics, who want the program delayed or scrapped. MIPS is slated to affect 2019 Medicare reimbursement for many physicians. However, writing in an article published online April 18 in the New England Journal of Medicine, members of the ACP's Performance Measurement Committee present an unfavorable assessment of many of the measures included in the MIPS/Quality Payment Program.

The authors, led by Catherine H. MacLean, MD, PhD, from the Center for the Advancement of Value in Musculoskeletal Care at the Hospital for Special Surgery in New York City, report that well over half of measures considered relevant to general ambulatory medicine were either not valid or of uncertain validity.

They raise concerns, for example, about a MIPS measure for high blood pressure that requires a that blood pressure of 140/90 mm Hg or lower be achieved in the clinic setting for all patients. "Forcing blood pressure down to this threshold could harm frail elderly adults and patients with certain coexisting conditions," they write.

MacLean and colleagues also said a MIPS measure on pain management might unintentionally promote overuse of opioid therapy.

Of 271 measures in the 2017 Quality Payment Program measures list, the ACP committee identified and rated 86 as relevant to ambulatory general internal medicine. Of those, they rated just 32 (37%) as valid. In contrast, they rated 30 (35%) as not valid and 24 (28%) as being of uncertain validity.

MacLean and colleagues called for "a time-out" to allow revisions to physician performance measurement.

"The fact that only 37% of measures proposed for a national value-based purchasing program were found to be valid with a standardized method has implications for physician-level performance measurement," they wrote.

The new Medicare requirements are only part of a maze of quality measures that physicians have faced in recent years, with other insurers also using their own sets of metrics. MacLean and colleagues note that 63% of physicians in a recent survey said these kinds of measures do not properly assess the quality of the care that physicians provide. Yet, the cost of reporting data needed for these measurements has been pegged at about $15.4 billion each year, or about $40,000 per physician.

To assess MIPS measures, MacLean and colleagues used a modified version of a method developed at RAND and the University of California, Los Angeles, for evaluating the benefits and harms of medical intervention. The ACP committee hypothesized that physicians would have more confidence in the system's ability to improve the health of patients if most of the MIPS/Quality Payment Program measures assessed were deemed valid using this process. But if a substantial proportion of the measures failed to prove valid, that would be a signal to consider changes to the new system, the authors write.

Another example of a MIPS measure that failed to be seen as valid is related to elder maltreatment screening and follow-up. The US Preventive Services Task Force has found insufficient evidence to warrant routine screening, MacLean and colleagues note.

"We believe the substantial resources required to screen large populations of elderly patients for maltreatment and to track follow-up would be better directed at care processes whose link to improved health is supported by more robust evidence," they wrote.

The newly published findings may add to the doubts about MIPS, said Paul B. Ginsburg, PhD, a researcher affiliated with the Brookings Institution. He reviewed the New England Journal of Medicine paper at the request of Medscape Medical News, complimenting the ACP committee on its work. The ACP paper highlights, for example, that the measurement cited on high blood pressure is "too crude" and could result in harm to patients, he said.

"This actually now makes us much less confident in what the quality measures might be accomplishing," Ginsburg told Medscape Medical News.

Ginsburg also serves on the Medicare Payment Advisory Commission, which in March made a formal recommendation to Congress that it scrap this system.

In an April 19 letter to top congressional lawmakers, ACP's president, Jack Ende, MD, said the organization continues to "support the original goals of" the Medicare Access and CHIP Reauthorization Act of 2015 that mandated creation of MIPS. He then flagged for the lawmakers the newly published ACP research and asked that Congress continue to "exercise its oversight authority" in pressing for changes in MIPS.

"We believe that physicians should not be penalized based on poorly designed measures," Ende wrote.

With MIPS, federal officials have created a system that largely will test how well physicians have learned to respond to CMS' payment incentive, and will not serve as a true reflection of the quality of their work, Robert A. Berenson, MD, a fellow with the Urban Institute, told Medscape Medical News in an interview.

Officials at the Centers for Medicare and Medicaid Services likely will find ways to soften the financial blow of MIPS on physicians, but lawmakers may not be anxious to soon make major changes in the program, he said. Many members of both parties still cite the Medicare Access and CHIP Reauthorization Act of 2015 as a rare recent example of productive relations between Democrats and Republicans. With MIPS, they wanted to build a pay-for-performance aspect into Medicare as they got rid of an older budget-control mechanism, known as the sustainable growth rate.

"It was bipartisan and it was bipartisanly wrong," Berenson said.

On coauthor reports personal fees from Academy Health/PCORI and Altarum Institute/RWJF outside the submitted work, and serving as the Immediate Past Chair of the Performance Measurement Committee for ACP. The other authors have disclosed no relevant financial relationships.

N Engl J Med. Published online April 19, 2017. Full text

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