Could the MedPAC Proposal Around MIPS End Up Being the Wrong Answer to the Right Question? | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

Could the MedPAC Proposal Around MIPS End Up Being the Wrong Answer to the Right Question?

March 20, 2018
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Does the MedPAC proposal really make sense in the context of the current moment in Medicare policy and payment?

As Associate Editor Heather Landi noted in her report Monday about the latest developments around the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law, and its component, MIPS (the Merit-based Incentive Payment System), the Medicare Payment Advisory Commission (MedPAC—an independent commission whose mandate is to advise Congress on Medicare payment and quality issues) this month issued its report to Congress, recommending that the MIPS program be eliminated and replaced 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 that proposal was included in the advisory group's recent report to Congress.

The members of MedPAC were quite explicit in their recommendations and assertions. In their March report to Congress, they wrote, “The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established a new framework for how traditional FFS [fee-for-service] pays for clinician services. The Commission supports the elements of MACRA that repealed the SGR [the sustainable growth rate formula for Medicare physician payment] and encouraged comprehensive, patient-centered care delivery models such as advanced alternative payment models (A–APMs). MACRA also created the Merit-based Incentive Payment System (MIPS), which measures individual clinicians in traditional Medicare on a set of measures that they choose.”

Among the things they assert: “MedPAC shares Congress’ goal, expressed in MIPS, of having a value component for clinician services in traditional Medicare that promotes high-quality care. However, the Commission believes that MIPS will not fulfill this goal and therefore should be eliminated.”

What’s more, they say in their report, “MIPS is premised on the assumption that Medicare can measure and pay for quality at the level of the individual clinician, but a system built on that assumption will be fundamentally inequitable for two reasons: (1) clinicians will be evaluated and compared on dissimilar measures, and (2) many clinicians will not be evaluated at all, because as individuals, they will not treat enough Medicare beneficiaries to produce statistically reliable scores. In addition,” they state, “MIPS imposes a significant reporting burden on clinicians (estimated by CMS as over $1.3 billion in the first year). MIPS scores are not comparable among clinicians because each clinician’s composite MIPS score will reflect a mix of different, self-chosen measures. MIPS is complex and inequitable, with different rules for clinicians based on location, practice size, and other factors, and in 2018 it exempts more clinicians than will participate.” And, “MIPS-based payment adjustments with be small in the first years, providing little incentive, and then arbitrary and possibly very large in later years, creating significant uncertainty for clinicians.”

As a result, they propose the following: “After a two-year deliberative process, the Commission recommends that the Congress eliminate MIPS and adopt an alternative approach for achieving the shared goal of promoting high-quality clinician care for beneficiaries in traditional Medicare.” What’s more, “To help improve the quality of care in Medicare, quality measures should be reliable, encourage coordination across providers and time, and promote change in the delivery system. Quality measurement should focus on population-based measures and give rewards or penalties based on clear, absolute, and prospectively set performance targets. In addition, quality measurement should not be overly burdensome for providers or divert resources needed for patient care.”

Provider leaders weigh in

As Landi notes in her report, “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.”

But even some provider associations that have complaints over MIPS do not necessarily support dumping MIPS altogether and replacing it with something completely new. 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.”