There is no shortage of opinions, and criticism, about the Medicare Access and CHIP Re-Authorization Act (MACRA), the federal government’s payment program that aims to push providers to transition from volume to value. More specifically, many providers have voiced frustration with the performance measures under MACRA’s Merit-based Incentive Payment System (MIPS).
The Medicare Payment Advisory Commission (MedPAC), a nonpartisan legislative branch agency that provides the U.S. Congress with analysis and policy advice on the Medicare program, has been vocal about its concerns and criticism of MIPS, and is, in fact, recommending in its March report to Congress, which was made available to the public last week, that federal legislative leaders eliminate MIPS and replace it with an alternative model of reimbursement.
MedPAC submits two reports to Congress each year, in March and in June. Back in January, MedPAC voted 14-2 to recommend scrapping MIPS and replacing MIPS with a new clinician value-based purchasing program, called the Voluntary Value Program (VVP), and this proposal was included in the advisory group's recent report to Congress.
MedPAC’s approach to a new value-based purchasing program is to allow clinicians to self-organize into groups that collectively assume responsibility for their patients’ outcomes. Under the VVP, clinicians can elect to be measured as part of a voluntary group and clinicians in voluntary groups can qualify for a value payment based on their group’s performance on a set of population-based measures, according to the report. The VPP would measure all clinicians on the same set of measures—clinical quality, patient experience and value.
In its 563-page report (the section on replacing MIPS starts on page 475), MedPAC says that the Commission supports the elements of MACRA that repealed the sustainable growth rate (SGR) and encouraged comprehensive, patient-centered care delivery models such as advanced alternative payment models (A–APMs). However, the Commission has concluded that MIPS “will not fulfill its goals and therefore should be eliminated.”
MedPAC concluded, according to the report, “that the MIPS program impedes the movement toward high-value care. MIPS will not succeed in helping beneficiaries choose clinicians, in helping clinicians collectively change practice patterns to improve value, or in helping the Medicare program to reward clinicians based on value.”
The March MedPAC report also lays out the Commission’s additional concerns and criticism: MIPS imposes a significant reporting burden on clinicians (estimated by CMS as over $1.3 billion in the first year) and MIPS scores are not comparable among clinicians because each clinician’s composite MIPS score will reflect a mix of different, self-chosen, measures. MedPAC also contends that MIPS is complex and inequitable, with different rules for clinicians depending on location, practice size, and other factors; and it exempts more clinicians than will participate.
As much as clinicians dislike aspects of MIPS, many physician groups and industry associations disagree with the proposal to eliminate MIPS—indicating a sort of “better the devil you know, than the devil you don’t” mentality. Anders Gilberg, senior vice president for government affairs at the Medical Group Management Association (MGMA), said in a statement, “MedPAC’s March Report is an indictment of MIPS as implemented. However, its conceptual ‘VVP’ alternative lacks details. MGMA believes there are steps that can be taken now to reduce clinician burden. CMS can begin by shortening the 2018 MIPS data reporting period from one-year to 90 days in the same way the Agency did for Meaningful Use in 2014, 2015, and 2016.”
In a Healthcare Informatics podcast interview, which was recorded back in January, David Barbe, M.D., president of the American Medical Association, said that he believes it is “premature” to abandon MIPS at this point. “We do believe there are significant improvements and opportunities in the MIPS program, but we’re not quite ready to abandon it, we think that’s premature. We’re not that far along in to the second year of the program; it has not given us as an industry and as individual physicians time to acclimate to this program.”
Barbe added, “We’re concerned that the [MedPAC] proposal suggests that the primary way, if not the only way, is through group reporting, and while that has some advantages, forcing physicians into group reporting, or making that the only way one can participate in what I’ll generically call value-based programs, is probably not right. Our industry is not a one-size-fits-all industry. We have some reservations, but we’re waiting to see more details of the proposal.”
In the report to Congress, MedPAC concedes that many have argued that MIPS should be given a chance to succeed and that considerable resources have already been invested in the program. However, MedPAC stated, “MIPS will continue to consume limited CMS and clinician time and resources, and the burden of MIPS will outweigh its value to Medicare beneficiaries, the Medicare program, and clinicians. Progress in a more useful direction is feasible. MIPS should be eliminated, and a VVP should be established to encourage clinicians to move in a more productive direction.”
Tim Gronniger, senior vice president of strategy and development at Kansas City-based Caravan Health, a builder of accountable care organizations (ACOs), notes that MedPAC, in its report, gave voice to many of the concerns and frustrations that clinicians have about MIPS. “The core problem with MIPS is there is a disconnect between what clinicians feel like is important for their practice and what we can actually measure in the practice. Many feel that it’s a lot of work for not a lot of benefit to patients.”
Gronniger contends that physicians participating in ACOs are better positioned in a post-MACRA world as they can qualify for shared savings under the Medicare Shared Savings Program (MSSP) and often report on a prescribed set of measures. "Whereas in the regular MIPS program, clinicians just have to try to find the easiest measures to report on," he says. "There is fairly significant payment consequences on the line, starting at 4 percent based on 2017 performance, but getting up to 9 percent by 2021; it’s a lot of money for your practice potentially on the line. So, the strong incentive for many individual clinicians is to find the easiest measures to report on. That is the most damning problem that MedPAC latched onto, and one that I agree with.”
Prior to working at Caravan Health, Gronniger served as deputy chief of staff and director of delivery system reform at CMS under the Obama administration, where he was involved in writing MIPS, yet he is no stranger to the program’s flaws.
He notes that CMS was required by the law [MACRA] to give clinicians enormous choice in the MIPS program. “I think it’s an intractable problem with the current design of MIPS, and one of the reasons why, even though I don’t think Congress should go with MedPAC’s recommendation, I do think Congress is going to eventually need to revisit the structure of the MIPS program.”
Gronniger says he disagrees with MedPAC’s alternative program to replace MIPS, the VVP, because it builds on measure that are entirely claims-based. “MedPAC’s recommended approach relies on measures that are not well understood by clinicians and that haven’t worked very well so far. For example, the value modifier uses claims measures around measuring total cost of care for a hospital stay for a physician, which is called the Medicare spending per beneficiary member. Any given physician’s performance on a measure like this is going to vary. If you could roll up five years of claims data, then you might have confidence that performance on this measure means something. But if you have to wait five years, then it’s not a practical measure to use in a pay-for-performance program where you’re trying to create incentives between performance, or what you do in clinical practice, and what Medicare pays you.”
As it stands, Gronniger does not anticipate that Congress will follow MedPAC’s recommendation of repealing MIPS and implementing the proposed VVP.
“I do think Congress should be providing incentives for participating in alternative payment models that are more clear and provide more direction than what MIPS does right now. I think the MIPS program, as it now currently exists, is too burdensome, is not impactful and doesn’t drive any significant change that justifies the costs that are borne by practices participating in the program. So, to me, that means eventually Congress should get involved and fix it.”
Despite of any potential changes to physician payment models under Medicare, Gronniger contends that the Trump Administration has provided some clarity on the direction for payment reform going forward.
“I think that last year there was a lot of uncertainty around whether this Administration was going to keep payment reform moving, around whether the CMMI [Centers for Medicare and Medicaid Innovation] was even going to survive, and I think a lot of that uncertainty has been lifted. We’ve gotten more clear statements of support for payment reform from the Administration over the last month or so. They have a new bundled payment program out, BPCI Advanced. I think it’s going to continue to be a pretty small piece of the puzzle for payment reform and Medicare, but it shows that they are not abandoning the project of making sure that physicians have a good number of options for participating in advanced alternative payment models,” he said.
He also noted that it is going to become increasingly important for physicians and health system leaders to pay attention to MIPS as CMS is required to begin publishing, at the end of this year, all the MIPS scores for every participating physician, including those who are exempt. “Ratings organizations like Yelp or Angie’s List or Consumer Reports are going to pick up those numbers and use them to create star ratings or letter ratings. And, even though the MIPS score is not meant to be graded on an A, B, C scale, it’s going to be turned into that by groups that don’t really understand the way it works. So, physicians who are otherwise totally competent are going to be getting D or F grades, or incomplete grades, where they were used to being A students their entire life. That’s going to start to affect patent decision-making and patient self-referral behavior, for elective procedures, in particular.”