MedPAC urges repealing MIPS

The Medicare Payment Advisory Commission is pushing for the immediate repeal and replacement of a Medicare payment system that aims to improve the quality of patient care.

To avoid penalties under MACRA, physicians must follow one of two payment tracks: the Merit-based Incentive Payment System, or MIPS, or advanced alternative payment models like accountable care organizations. MedPAC wants to junk MIPS as it feels that it's too much of a burden for physicians and won't push them to truly improve care. "Time is of the essence to develop an alternative for MIPS," said David Glass, principal policy analyst at MedPAC. It "will not achieve the goal of identifying and rewarding high-value clinicians." While not a policy-creating body, MedPAC is an influential voice for both Congress and the CMS. Most recently its site-neutral policy for hospital off-campus facilities was finalized in a rulemaking last year. Under MIPS, physician pay is based on success in four performance categories: quality, resource use, clinical practice improvement and "advancing care information" through use of health information technology. The advancing care criteria is based on the government's meaningful use program, which is used to decide whether doctors should be rewarded for using EHRs. The CMS estimates that up to 418,000 physicians will be submitting 2017 MIPS data. But MIPS is severely flawed, according to MedPAC. It is designed primarily to measure how doctors perform, such as whether they ordered appropriate tests or followed general clinical guidelines, rather than if patient care was ultimately improved by that provider's actions. Another flaw is that MIPS lets clinicians choose the measures under which they're evaluated. The concern is that they'll choose measures on which everyone tends to perform well. There are also MIPS categories that rely solely on clinicians self-reporting whether they complete certain activities. So physicians are likely to score high on these measures, making it difficult to measure differences in performance, MedPAC said. A final concern is the costs to report and track MIPS measures. The CMS estimates that providers will spend over $1 billion to do so in 2017. That's too much money compared to what MIPS may save, or even the rewards that providers could get. MACRA only allows for up to $500 million each year in positive pay adjustments for performing well under the system. To that end, the commission suggests junking MIPS. Then, all Medicare physicians not in an alternative payment model, or APM, would have 2% of their payments withheld. The CMS estimates that anywhere from 180,000 to 245,000 clinicians will be in an APM by the end of 2018. After the money is withheld, providers would be given two options. To get the money back, doctors not in an APM could be a part of a new voluntary pay model in which they join a group of clinicians and are evaluated on performance-based measures, such a mortality rates of patients or rate of per beneficiary spending following hospitalization. The measures would be claims-based, meaning that the CMS, not providers would have to track clinician performance. This approach would reduce regulatory burden now placed on doctors, MedPAC said. The other option is to remain in fee-for-service and lose out on the 2% of reimbursement that was withheld. MedPAC commissioners were in near universal agreement that MIPS should be repealed. "We really have to get rid of MIPS," said Dr. Rita Redberg, a commissioner and cardiologist at the University of California at San Francisco. "No one went into medicine to check all these boxes." Dr. Alice Coombs, a commissioner and critical-care specialist at Milton Hospital and South Shore Hospital in Weymouth, Mass., was the sole holdout, saying providers are just now getting used to it. She suggested it could be tweaked to be more performance-focused. She was also concerned that the new model would place specialists at a disadvantage since they have different patterns of care than a primary-care provider. For instance, an addiction specialist may use a lot more resources in caring for a patient than other provider types. Despite everyone else agreeing that MIPS should end, none of the panel members supported the new model as it was presented Thursday. One gripe was that doctors may be tempted to just stay in fee-for-service if they are given an option to do so, according to Dr. Craig Samitt, a MedPAC commissioner and chief clinical officer at Anthem. "A 2% penalty will not drive behavior change,"Samitt said. Provider groups that would form under the new model could block doctors who treat a large number of high needs patients, like those dually eligible for Medicare and Medicaid, from joining them, thus robbing them of a chance to get back the revenue that was withheld from them, added David Grabowski, a commissioner and healthcare policy professor at Harvard Medical School. MedPAC staffers agreed that there were still scenarios they needed to iron out with their proposal. "What happens if the only ones that come back are those that think they'll perform well?" Kate Bloniarz, senior analyst at the commission asked. "We don't have an answer for that yet." MedPAC staff plan to iron out their idea and present draft recommendations in December. If they are ultimately approved by commission members, they'll appear in their annual March report.