MIPS is on the Chopping Block—and Just When You Thought You Might Get the Knack of It

Posted on 14 Mar, 2018 |comments_icon 0|By Elizabeth
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If it happens, it won’t happen soon, not until 2019 or 2020—but happen, it may. MIPS could be repealed.

The Medicare Payment Advisory Commission (MedPAC) voted 14-2 to ask Congress to repeal and replace MIPS.

Who or what is MedPAC?

MedPAC is an independent legislative body established in 1997 (by the Balanced Budget Act of 1997) with the directive to advise Congress on issues affecting Medicare program administration.

Mark E. Miller, MedPAC’s former executive director, explains that it is “required by law to provide analysis and ideas to make changes to Medicare.” But, Miller says, “Just to be clear, it makes recommendations to Congress. Congress is not required to follow them.”

Prior to the MedPAC decision to solicit congressional intervention to scrap MIPS, voting members attended an internal presentation that outlined why MIPS is doomed to fail:

  1. Replicates flaws of prior value-based purchasing programs
  2. Burdensome and complex
  3. Much of the reporting information is not meaningful
  4. Scores not comparable across clinicians
  5. MIPS payment adjustments will be minimal in first two years, large and arbitrary is later years.
  6. MIPS will not succeed in helping beneficiaries choose clinicians, helping clinicians change practice patterns to improve value, or helping the Medicare program to reward clinicians based on value.

MedPAC believes that the quality measurement process has become “highly overbuilt”. Miller says, “We think that that results in a burden to providers and particularly physicians in small physician practices.”

In monetary terms, the burden amounts to $1.3 billion in clinician costs nationwide, as estimated by CMS. But the heart of the issue under debate isn’t the burden imposed on clinicians. The controversy centers on the value gained from this burden.

Is this burden imposed on clinicians achieving its ends? The consensus is—no.

“We’re collecting too many measures,” Miller says, “and we’re collecting measures that have little to do with actual outcome—a lot of process measures.”

Tim Gronniger, senior vice president at Caravan Health and former Chief of Staff and Director of Delivery System Reform at CMS, says, “Allowing broad clinician choice means that each individual clinician will end up reporting different measures, directly undermining MIPS’s ability to help patients compare clinicians.”

In their article, Congress Should Replace Medicare’s Merit-Based Incentive Payment System, Gronniger and his colleague point out a litany of MIPS effects that clash with the program’s goal to move Medicare toward outcomes- and value-based reimbursement in efforts to improve patient care:

  • “Allowing broad choice of measures undermines the effectiveness of MIPS’s direct financial incentives. Because of this flexibility, clinicians will often be able to select quality measures for which they are already attaining a very high score.”
  • “Similarly, clinicians will frequently be able to achieve the maximum score under the practice improvement and advancing care information categories purely by reporting on activities they were planning to undertake anyway.”
  • “Clinicians’ ability to achieve the maximum score (or a very high score) by merely focusing on “easy” measures and activities will greatly diminish the incentives to improve patient care that MIPS would otherwise have created.”
  • “The measures and activities where it is easiest for a particular clinician to achieve a high score will generally not be the measures and activities where additional effort would pay the greatest dividends for Medicare beneficiaries and the Medicare program.”
  • “This risk is magnified by the fact that each of these three performance categories includes measures that are not obvious priorities for quality improvement efforts.”

To top off Gronniger’s list, a new study lead by Eric Roberts may deliver the final nail in MIPS’ coffin. The study showed that the Medicare Value-Based Payment Modifier (VM), which measures quality and cost among physician group practices, fails to provide a positive effect on care quality or spending. Worse, warns Roberts, “if changes aren’t made, value-based payment models will continue to shortchange the poor.” The program, as is, shifts “money away from physicians who treat sicker, poorer patients to pay for bonuses that reward practices treating richer, healthier populations.”

Those Opposed Say…

The MedPAC vote is not without opposition. To the contrary, the opposition has been immediate and widespread, with top physician groups protesting that they’re not ready to dump MIPS.

President David O. Barbe, president of the American Medical Association (AMA), spoke out against the move and asked Congress to pass their proposal, which would give CMS time to fix MIPS. “The AMA agrees that MIPS needs to be simplified and has methodological issues that are problematic for physicians,” he wrote in an emailed statement. “The best remedy is to fix MIPS rather than jumping into another sweeping change that has not been fleshed out and would have many of the same methodological issues as MIPS.”

Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association (MGMA) said of the MedPAC proposal, “It would conscript physician groups into virtual groups and evaluate them on broad claims-based measures which is inconsistent with the congressional intent in MACRA to put physicians in the driver seat of Medicare’s transition from volume to value.”

The Alliance of Specialty Medicine, which represents more than 100 specialty and subspecialty physician societies, wrote to MedPAC’s Chairman Francis J. Crosson, saying, “We urge you to withdraw your forthcoming recommendation, which diminishes the important role of specialty medicine in Medicare. Instead, the Commission and staff, under your leadership, should work toward a new recommendation that would improve aspects of the MIPS program that remain a challenge for all clinicians.”

MedPAC’s Proposal—The Voluntary Value Program

MedPAC wants to replace MIPS with their “Voluntary Value Program,” which a nice ring to it. After all, how bad could voluntary be? What’s behind all the opposition?

Well, the short answer appears to be the program’s push to move MIPS participants, which is the majority of MACRA-eligible clinicians, over to the APM track. This isn’t entirely true, but it is largely true. And to be fair, MedPAC and its supporters have raised valid concerns to justify such a transition.

Physician groups oppose this, however, because the requirements of APMs participation are daunting for all but large, well-financed institutions.

Still, the very existence of MIPS discourages participation in the more rigorous APMs.

Gronniger and fellow writers “recommend that Congress eliminate MIPS and expand and improve incentives for Advanced APM participation.” MedPAC’s view here is that the signals should be stronger to move to APM. In fact, in its internal presentation, its stated goal is to prepare clinicians to participate in Advanced APMs.

“One very direct action is to deal with the $500 million extraordinary performance bonus, which is on the MIPS side of the legislation, potentially repurpose those dollars to the APM side, and give greater reward on that side,” suggests Miller.

MedPAC’s proposed Voluntary Value Program orients quality measures toward population measures rather than individual physician and process measures. In its basic components, the design includes:

  • A withhold applied to all fee schedule payments
  • Then, clinicians can choose from the following:
    1. Elect to join a voluntary group and have their performance assessed at the group level
    2. Join an Advanced AMP and receive their withhold back
    3. Make no election and lose their withhold
  • Voluntary group performance will be assessed using uniform population-based measures in the categories clinical quality, patient experience, and value.

Gail R. Wilensky, who chaired MedPAC from 1997 to 2001, describes the program, saying, “Physicians would have 2% of their fee-for-service payments withheld. To get the withheld money back, physicians would have to join an Advanced APM or be part of a (real or virtual) group that is evaluated on population-level performance measures such as mortality and readmission rates, potentially preventable admissions, and patient experience. MedPAC also proposes that the measures be based on claims, which would mean that the burden would be on CMS rather than clinicians to provide the relevant data. Clinicians who do not participate would lose the 2% that was withheld.”

Gronniger asks for quick action. “We recognize that Congress may be tempted to wait for several years of experience under MIPS before considering major changes like these, but that would be a mistake. Forging agreement on a system to succeed MIPS will take time and effort. That work should begin as soon as possible.”

Speak Up or Live with the Decision

You may not like MIPS for the hefty burden it imposes, but MIPS is as good as it gets in terms of benefit to burden ratio. You might consider taking Wilensky advice to heart: “Practicing physicians need make their views about the MIPS and its alternatives known to their representative medical groups and, if necessary, to their representatives in Congress as well. In the past, practicing clinicians have been woefully bad at making their voices heard. Now is a good time for that to change.”

Learn More

In the meantime, don’t let piecemeal information or complex, barely-intelligible MACRA guidelines torpedo your MIPS earnings. Gear up for payment rewards now with TCI’s MACRA Quality Measures Guide 2018.

References:

Buntin, Melinda B.; Miller Mark E. Why Does MedPAC Matter? NEJM Catalyst Insights, February 5, 2018. Available at: https://catalyst.nejm.org/medpac-matter-mark-miller/

Commins, Jim. Value-based Payments Must Address Patient Mix. HealthLeaders Media, Dec. 2017. Available at: http://www.healthleadersmedia.com/quality/value-based-payments-must-address-patient-mix.

Fiedler, Matthew; Gronniger, Tim; Ginsburg, Paul B.; Patel, Kavita; Adler, Loren; Darling, Margaret. Congress Should Replace Medicare’s Merit-Based Incentive Payment System. Health Affairs, February 26, 2018. Available at: https://www.healthaffairs.org/do/10.1377/hblog20180222.35120/full/.

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