Although it’s just a few months into year one of MACRA’s Quality Payment Program, there have already been rumblings from stakeholders that certain provisions of the outcomes-based program may need a makeover.
As a reminder, MACRA, or the Medicare Access and CHIP Reauthorization Act of 2015, includes two payment tracks that eligible Medicare clinicians can take part in that will determine their payment adjustments in future years. Early on in the program, most of these clinicians are expected to participate in the less risky Merit-Based Incentive Payment System (MIPS) track as opposed to the Advanced Alternative Payment Models (APMs) track, according to estimates from the government.
MIPS, which streamlines existing quality reporting programs such as those under meaningful use, the Physician Quality-Reporting System (PQRS), and the value-based payment modifier, while adding a clinical practice improvement category, involves more data reporting on the part of doctors, but indeed comes with less risk for losing money. The final score earned by a clinician for a given performance year then determines MIPS payment adjustments in the second calendar year after the performance year.
But it’s the details and complexities within these MIPS performance categories that have some experts concerned. Last October, just a few days before the MACRA final rule came out, I interviewed Niam Yaraghi, Ph.D., a fellow in the Brookings Institution's Center for Technology Innovation, who did not hold back in his thoughts about MIPS, calling the system “an open invitation to cheating.” Yaraghi’s sentiments, summed up, were essentially that: 1) much of the data reporting that’s involved is self-reporting, meaning that physicians will game the system; 2) for the MIPS quality component, clinician-to-clinician comparison becomes tough since no two doctors have to report on the same measures; and 3) there are delayed reporting feedback loops, meaning clinicians don’t get real-time feedback to let them know how they’re doing.
More recently, I also spoke to Rita Numerof, Ph.D., co-founder and president of St. Louis-based consulting firm Numerof & Associates, who had very similar thoughts as Yaraghi. Numerof, who’s been in healthcare consulting for 25 years, said it’s not as much about the MIPS reporting itself, but rather the validity and accuracy of it. She gives an example: “Say that [you and I] are both primary care physicians and a patient is deciding which one of us to see. I have chosen to report publicly on the areas that I’m doing a stellar job in and you are doing the same thing for the areas you’re doing great in, but there is no correlation between those [areas] at all, and there are other measures that we are also reporting on that may have no bearing to each other. We get [scores]; maybe I get a 4 and you get a 3.5, but does my score make me better? No, it depends on the elements that go into those scores, and were those elements even relevant to the patient’s choice on how to select a primary care doctor?” Meanwhile, regarding self-reporting, Numerof also agreed with Yaraghi in that doctors can easily “fudge the data.”
The idea, as perceived by some, that clinicians self-reporting on quality measures and being compared to others in their specialty based on unequal conditions is one that certain folks see as unfair. It’s also something that’s not new in healthcare, either. Yaraghi brought up that Medicare star ratings on nursing homes are also taken at face value and based on data sent to the government by the organizations themselves. The New York Times reported in 2014 that “many top-ranked nursing homes have been given a seal of approval that is based on incomplete information and that can seriously mislead consumers, investors and others about conditions at the homes.”
For Medicare clinicians partaking in MIPS, the domino effect on the industry could be similar. Numerof speculated that a physician’s patient volume could be impacted as consumers are now more likely to turn to a simple, rolled up score that’s publicly available to understand a physician’s overall performance. But if that score isn’t based on accurate and reliable data, patients could be making crucially important healthcare decisions with a lack of valid information at hand.
What’s more, it’s no secret that providers are unhappy with the burden that quality reporting puts on them, and there is a feeling amongst some industry stakeholders that MIPS does nothing to alleviate that load.
Back in February, for example, the Medical Group Management Association (MGMA) called on federal healthcare officials to simplify MIPS so that practices can prioritize effective improvements to patient care. MGMA offered an example: “One of the principal goals of MACRA was to consolidate three disparate and complex federal quality reporting programs into one. Yet MIPS continues to take a siloed approach to reporting, as it consists of four distinct components under one broad umbrella.” The association group suggested that reporting once should count toward the overall MIPS score, rather than merely toward bonus points. “MIPS should not reward the quantity of reporting but the quality of care provided to patients,” MGMA said.