MedPAC Chief Expects Waning Support for Medicare's MIPS

Kerry Dooley Young

December 12, 2019

WASHINGTON ― The leader of an influential federal advisory panel predicts there will be waning support in the years ahead for Medicare's Merit-based Incentive Payment System (MIPS).

Francis J. Crosson, MD, chairman of the Medicare Payment Advisory Commission (MedPAC), touched on the future of MIPS during a larger discussion of physician reimbursement on December 5.

MedPAC last year recommended Congress scrap MIPS and replace it with a new system for assessing the quality of care provided in Medicare's fee-for-service program, as reported by Medscape Medical News.

The Centers for Medicare & Medicaid Services (CMS) and Congress allowed many accommodations for clinicians in the start-up phase of MIPS. This approach contributed to paltry initial payouts for stand-out scorers, with more clinicians competing to divvy up a pool of $500 million for annual MIPS bonuses. The first payments, made this year for 2017 performance, allowed a maximum gain of 1.88%.

CMS intends to toughen its standard to increase the maximum MIPS payouts for top scorers, as the American Medical Association has reported in a primer of the Medicare physician fee schedule. This means more clinicians likely will face cuts because of lower MIPS scores as the maximum penalty rises to 9% from 7%.

"The support within the physician community for this particular form of payment update is going to erode as we get larger and larger differences based on very small putative changes in quality," Crosson said about MIPS at the December 5 meeting.

But there is no sign Congress is likely to reconsider MIPS, which it created in the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, according to Crosson.

"There may well be some further stronger consideration about changing things, but I think we have a little bit of a way to go at the moment," he said.

"A Giant Mess"

Democratic and Republican lawmakers applauded the passage of MACRA in 2015. Enactment of the law relieved them of an annual scramble to prevent slated cuts to Medicare payments to physicians. In the 1990s, Congress attempted to control the growing cost of doctors' pay with a method known as the sustainable growth rate (SGR).

But Congress then acted multiple times to stop the SGR from cutting Medicare payments for doctors before finally scrapping it entirely through MACRA. The 2015 law created MIPS and also called for alternative payment models (APMs), which were intended to spur greater coordination and improve patient care.

"There was euphoria in many quarters at finally repealing the much despised SGR," said Jonathan Oberlander, PhD, of the University of North Carolina at Chapel Hill, who is the author of The Political Life of Medicare. "But the further along we go with MIPS, the more that euphoria fades and the more evident it is that the SGR's replacement has its own problems."

In the end, Congress may have to return to questions about how Medicare pays physicians.

"Those problems are likely to produce growing controversy and scrutiny over time," Oberlander said in an email to Medscape Medical News. "There is no permanent technical fix to physician payment, which is fundamentally a political problem."

Policy experts have stressed the low expectations for improved patient care from MIPS. Some physicians may be able to more easily "game" MIPS for higher payments as well, they say.

"Those with more sophisticated information systems and analytic capabilities can game the system more easily, potentially exacerbating disparities" in medical care, wrote J. Michael McWilliams, MD, PhD, of Harvard Medical School, in a 2017 opinion article in the Annals of Internal Medicine, titled "MACRA: Big Fix or Big Problem?"

In an email exchange with Medscape Medical News last week, McWilliams described MIPS as "a giant mess ― payment policy at its worst."

"It should be repealed and never repeated," he wrote.

Mollie Gelburd, associate director for government affairs at the Medical Group Management Association, said there will be sustained calls for Congress to revise the quality-measurement programs created through MACRA.

Last year, lawmakers made technical corrections to the MACRA payment approaches, she said.

"That made for a smoother on-ramp to full MIPS participation, such as reducing the weight of the cost category, which has continuing methodological flaws that hold physicians and groups accountable for costs beyond their control," Gelburd told Medscape Medical News.

Physician organizations have asked Congress to address the perverse incentives in the quality programs, she said.

MACRA was intended to encourage physicians to move into APMs that emphasized coordination and improvement of care. But the APM programs have not been as robust as had been hoped, Gelburd said.

"The APM bonus expires in 2024. At that point, the MIPS adjustments will be a positive 9%, so it might be more attractive for providers to stay within MIPS and throw their hat in the ring to get that positive 9%, which runs counter to the entire statutory intent of MACRA, which was to get people into APMs," she said.

"If you have a program like MIPS, which currently is viewed by the physician community as a compliance or reporting program with little to no clinical benefit to it, then all you are doing is really driving up administrative costs without improving patient care," Gelburd added. "We know that that's an issue."

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