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

March 20, 2018
The Medicare Payment Advisory Commission, or MedPAC, has proposed that Congress eliminate the MIPS program and replace it with a new value-based purchasing program—but does that proposal make sense in the current policy and payment moment?

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 The Commission supports the elements of MACRA that repealed the SGR [the sustainable growth rate formula for Medicare physician payment] and encouraged comprehensive, patient-centered care delivery models such as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.”

Meanwhile, in a Healthcare Informatics podcast interview, which Landi conducted back in January, David Barbe, M.D., president of the American Medical Association (AMA), 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,” Dr. Barbe told Landi at that time. “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.” And, he 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.”

Indeed, in its 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.”

The devil you (sort of) know…?

So, where does all of this leave us? Well, in something of a conceptual and policy pickle, to be honest. So let’s parse this a bit, shall we?

To begin with, MACRA and MIPS were created as a remedy to the ridiculous situation that we had for a decade with the SGR, which had been passed with bipartisan consensus by both houses of Congress, back in 1997, and which in turn had replaced the old MVPS (Medicare Volume Performance Standard) that had been in place before the SGR. The core problem, of course, was that the SGR was never fully enacted, because members of Congress from both political parties lacked the courage of their convictions, and feared the rage of organized medicine, and therefore, the physician pay cuts called for under the SGR legislation, were never enacted. By January 2013, those cuts were estimated at an eye-popping 27.4 percent; they were estimated to be 24 percent in April 2014. So the passage of MACRA, which had firm bipartisan support, finally eliminated that sword of Damocles that had been hanging over physician payment for 16 years.

The theory behind MIPS made a lot of sense, and, it must be stated once again, had very broad bipartisan support. Of course, the devil is always in the details, and in this case, the details ended up being particularly thorny. As already noted above, the MedPAC commissioners noted in their report that “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,” they underscored, “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.”

On a far more basic level, physicians in practice are simply finding MIPS too complex to work with, and therefore, are finding it to be too much of an administrative burden. The question is, would this “Voluntary Value Program,” or “VVS,” be any better? What’s more, even if were an improvement over MIPS, would the transition to it be worth the additional hassle? Or would it be better to gradually streamline the MIPS reporting requirements instead?

U.S. physicians in practice are feeling oppressed and beleaguered these days, and that fact is understandable. Do they deserve “relief”? Yes—in certain ways, and along certain dimensions. But that element needs to be parsed, too. For one thing, as much as they may hate it on a day-to-day practice, the reality on the policy and payment levels, is that pay for performance is here to stay in healthcare; there’s simply no way that the U.S. healthcare system, particularly the Medicare program, is going to go back to unfettered, non-directed fee-for-service payment, not with total U.S. healthcare spending set to increase 70 percent over the coming decade, to an annual total of $5.7 trillion, and 19.7 percent of GDP. Even the current 5.5 percent healthcare inflation rate is simply too high, given the cost trajectory we’re on as a national healthcare system. So value-based purchasing will only accelerate, not decelerate or reverse.

That said, physicians in practice do have four very legitimate complaints in this area: that there are too many quality measures overall; that they are not all aligned (for example, Medicare versus private-payer sets of measures); that they are far too often process-based, and don’t truly measure differences in actual care quality; and finally, that, too often, the measures reward or penalize doctors for things that are not truly within their scope of control.

In that context, no one has claimed that the initial set of measures within MIPS is the be-all and end-all, the final set of measures that will be valuable forever; quite the opposite, in fact. Federal healthcare officials, and all others, involved in the evolution of MIPS and MACRA, agree that the measures need to be refined, and in some cases, changed, over time.

The question is, how, in what ways, and when.

And my own instinct, in reading this broad, somewhat vague proposal by the MedPAC commissioners, is to say that one of the key elements in that proposal—to allow physicians to gather together in voluntary pods of some sort, to be measured in groups, according to quality, would actually add yet another element of complexity to this, as the vast majority of practicing physicians are just figuring out what to do about MIPS, versus attempting to participate in advanced alternative payment models. I just see a lot of chaos breaking out, at a time when practicing physicians need to move forward, very quickly, under MACRA.

So while the MedPAC commissioners have put forward some interesting ideas, and while some physicians in practice might leap up to endorse it, it’s difficult to embrace their proposal at this time and in this context; things are simply too unsettled right now. And, though it might not be popular to say so, in a way, this moment reminds me of the first year under the meaningful use program. That was difficult, too, but in the end, nearly all Medicare-accepting hospitals, and more than 90 percent of Medicare-accepting physicians, did implement electronic health records and move forward, under meaningful use.

So for right now, really, the only practical option seems to be to move forward with the admittedly flawed MIPS program and fix it as things move forward. Sometimes, in an imperfect world, working with an imperfect system is preferable to introducing more complexity to that system in an effort to make it more perfect. In other words, realism can at times lead to a better outcome than can perfectionism. But, stay tuned to see what happens next; this play has several more acts up ahead!

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