Senators Seek Feedback on Medicare's Pay Models Under MACRA

Kerry Dooley Young

May 09, 2019

WASHINGTON — Members of a powerful Senate committee said during a Wednesday hearing that they are keeping tabs on the administrative burdens of Medicare programs meant to tie physicians' pay to judgments about the quality of care they provide.

The Senate Finance Committee does not appear to have any immediate plans for making major changes to the programs created by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

But during the hearing, members of the Finance Committee showed clear sympathy with physicians' complaints about the Merit-based Incentive Payment System (MIPS).

"When it comes to assessing quality, the goal of implementing this new system is not to have doctors checking boxes all day long," Sen. Ron Wyden of Oregon, the ranking Democrat on the committee, told the witnesses at the hearing.

Medicare's MIPS system is part of a broad move among insurers to try to tie physicians' payment to judgments about their performance. So far, this effort has forced physicians to spend many hours a day entering data, some of which have little immediate relevance to their role in patient care.

Medicare has "retrofit a tired fee-for-service payment model with sporadic measures, which do not make sense to the surgical community," Frank Opelka, MD, medical director for quality and health policy of the American College of Surgeons, told the Senate Finance Committee.

The agency's measurements for implementing MACRA focus heavily on preventive care and screening for chronic conditions such as diabetes, putting many specialists at a disadvantage, according to Opelka.

"In other words, surgeons receive credit for how well their group practice immunizes a population instead of ensuring a patient has safe surgical care," Opelka said.

Barbara L. McAneny, MD, president of the American Medical Association (AMA), spoke about how her cancer practice faced high costs and received little reward from MIPS. As a leader within AMA, she said she wanted to set an example and show that a rural practice could do well with the new metrics.

She scored 100 on MIPS, which put her in line for a payment increase of 1.88% — initially. Including an adjustment to her reimbursement, the payoff for the perfect score was about $34,000. McAneny tallied the costs she said were needed to get the high MIPS score, including payments to her electronic medical record provider.

"When I added up everything that I had to do in terms of paying staff overtime to make sure the data were accurate, I lost $100,000 to score that perfect score," she said.

Sen. Pat Roberts (R-KS) used a sports analogy in response to McAneny's observations about Medicare's payments through MIPS.

"When you score a hundred, it's like all of a sudden the referees, the people who wear the stripes in the basketball game, say, 'I'm sorry. You only scored 80 and you lost the game,' " Roberts said.

Less Complexity

John S. Cullen, MD, president of the American Academy of Family Physicians (AAFP), asked the senators to consider several major changes to the payment systems created by MACRA. These include reducing the complexity in MIPS scoring and eliminating the MIPS alternative payment model (APM).

The Centers for Medicare & Medicaid Services created the MIPS APM, for which there is not a specific authority included in the 2015 MACRA law, according to AAFP's written testimony.

The AAFP said the participants in the MIPS APMs tend to be larger practices that are part of accountable care organizations. Because of the resources available to these practices, their higher scores could skew the MIPS performance threshold.

Practices with these advantages should move toward a more challenging set of Medicare metrics, known as the advanced alternative payment models, AAFP said. This was the lawmakers' intent when they wrote the MACRA law, the group said.

At the hearing, both the AAFP and the AMA asked the senators to reconsider their plan to hold Medicare's physician reimbursement flat or to make few changes for many years.

The 2015 law allowed for what the AMA, in its written testimony submitted to the finance committee, called "modest positive payment updates" for a few years after its enactment, with a 6-year freeze to begin in 2020. After this, MACRA calls for increases of 0.75% or 0.25% for physicians participating in APMs or MIPS, respectively, the AMA said.

The AMA noted that Medicare's board of trustees had flagged physician payment as a concern in its 2019 report, released last month. The trustees said that in the future, people enrolled in Medicare might struggle to find physicians willing to accept them as patients. Federal law now is on a path to make the program a far less generous payer than other insurers in the coming decades.

Thus, the AMA called on Congress to change MACRA's financial terms now to "provide physicians with a stable and sustainable revenue source that allows them a margin to invest in practice improvements."

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