The Medicare SGR replacement bill that most likely will pass Congress this week makes sweeping changes to Medicare's programs for rewarding or penalizing physicians on quality, cost and their adoption of electronic health records.
It also gives medical specialty boards, which certify and recertify physicians, an unwarranted role in how those rewards or penalties will be parceled out. Other stakeholders will want to weigh in as the CMS hammers out details of the new Merit-Based Incentive Payment System (MIPS).
The law not only scraps the sustainable growth-rate formula for physician payment, it consolidates the diverse programs for rewarding or penalizing physicians. The CMS no longer will calculate separate payments for reporting quality measures, improving performance or meeting meaningful-use standards.
Instead, the CMS will substitute a composite MIPS score for each physician participating in the Medicare program. When measured against clinical peers, a physician's score could result in the agency rewarding or penalizing him or her up to 5% of annual revenue starting in 2020. That rises to 9% of revenue for 2022 and beyond.
While the program is designed to be revenue-neutral, it allocates $500 million for rewards, just in case a majority of physicians turn out to be like the kids at Lake Wobegon and achieve universally high composite scores.
The overall score will be based on how well participating physicians perform in four separate categories: quality measures (30% of the total); resource use (30%); achieving meaningful use (25%); and clinical practice-improvement initiatives (15%). Each component will be determined by agency rulemaking and stakeholder input.
But some stakeholders are being given a greater say in the process (others are invited to participate, of course). The law, for instance, asks “eligible professional organizations” to recommend quality measures for use in the program. It defines eligible professional organizations as “nationally recognized specialty boards of certification.”
It also says physicians can achieve the maximum score on the clinical practice-improvement component by being part of a certified medical home or “comparable specialty practice.” The law gives “eligible professional organizations” the ability to make that determination. The bill also mentions “practice assessments related to maintaining certification” as one way to achieve a maximum clinical practice-improvement score.
The special role given physician specialty boards in the SGR replacement bill heightens the stakes in the recent controversy swirling around the costly and complicated recertification process at the American Board of Internal Medicine, one of the largest boards in the nation. A rival group is seeking to substitute continuing medical education credits for recertification test-taking, which the ABIM and patient and consumer advocacy groups oppose.
The flare-up has brought some of the more unsavory and unscientific aspects of the self-regulating physician recertification process to light. A recent New England Journal of Medicine perspective by ABIM critic Dr. Paul Teirstein of the Scripps Clinic noted that the latest studies have shown no relationship between physician recertification and performance on quality measures—the very task given to certification boards in the SGR replacement bill.
Teirstein also accused the ABIM of being “a private, self-appointed certifying organization” that charges exorbitant fees “unfettered by competition” for its products and tests.
The certification boards aren't major powerhouses on the Washington lobbying scene. Last year, for instance, the ABIM spent only $160,000 on the lobbying firm of Mehlman Castagnetti Rosen Bingel & Thomas, according to Senate lobbying records. But that firm's chief healthcare lobbyist, Dean Rosen, once served as an adviser to then-Senate Majority Leader Bill Frist (R-Tenn.), and apparently still has good connections with the staffers who drafted the language of the SGR replacement bill.
As we editorialized here two weeks ago, a permanent end to SGR is the right thing to do. And creating MIPS to replace multiple rewards programs will lessen the administrative burden on physicians and physician practices, and incentivize them to move toward value-based care payment models.
But other stakeholders will need to remain vigilant to ensure that self-interested physician specialty boards don't play an outsized role in setting the parameters of the program—especially when it comes to determining what constitutes quality and clinical-practice improvement.