MedPAC finalizes its proposed MIPS replacement

The Medicare Payment Advisory Commission has finalized a recommendation that urges the 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. On Thursday, the Commission presented a draft recommendation that will be voted on in January. It asks Congress to eliminate MIPS and establish a new voluntary value program in which clinicians join a group and are compared to each other on the quality of care for patients. Physicians who perform well would receive an incentive payment. If passed by commissioners, the suggestion will be published in the advisory group's annual March report to Congress. MedPAC staffers continued to push for swift action in repealing MIPS. The longer doctors operate under MIPS, the more likely there will be opposition to junking the system because they have invested resources and time to implement it, according to Kate Bloniarz, senior analyst at the commission. "We believe MIPS is inequitable, burdensome and will not improve care for beneficiaries," Bloniarz said. MedPAC wants to junk MIPS because it believes the system is too burdensome for physicians and won't push them to improve care. Members have criticized the program's design for primarily measuring how doctors perform, including whether they ordered appropriate tests or followed general clinical guidelines, rather than if patient care was ultimately improved by that provider's actions. The CMS estimates that up to 418,000 physicians will be submitting 2017 MIPS data. Agency officials agree the system should do more to judge providers on outcomes, but haven't gone so far to suggest repealing the system. Commissioners have split about the best path forward. All but one support eliminating MIPS. "I would put MIPS in the bad pay-for-performance hall of fame," said David Grabowski, a commissioner and professor in the Department of Health Care Policy at Harvard Medical School. But that doesn't mean there's a lot of enthusiasm for MedPAC's replacement proposal. "We say on one hand it's urgent to repeal MIPS, but I don't think we have a good grasp of what's needed in terms of performance measures," said Kathy Buto, a commissioner and independent health policy consultant in Arlington, Va. There was a concern that the new model didn't do enough to actually move providers to value-based care. MedPAC's idea is that all Medicare physicians not in an alternative payment model would have a small amount of their payments withheld. The commission had originally suggested 2%, but now they're debating whether to include the figure in their recommendation or leave it up to Congress and the CMS. Providers would have two options for their withheld payments: either join a new voluntary pay model to recoup the money or stay in fee-for-service and lose out on the funds. The new pay model would evaluate groups of clinicians on performance-based measures, such as patient mortality rates or spending per beneficiary following hospitalization. The measures would be claims-based. The CMS, not providers would have to track clinician performance. This approach would reduce regulatory burden now placed on doctors, MedPAC said. Commissioners were concerned potentially losing 2% of Medicare reimbursements may not be a big enough incentive to join the new model. David Glass, principal policy analyst at MedPAC, conceded that point, saying Thursday that the potential incentives of the new model were modest enough that doctors may not think it's worth it to make the investments needed to implement it. However, eliminating MIPS may inspire providers who are ready for value-based payment programs to pursue an APM, which has greater rewards potential, Glass said. Dr. Alice Coombs, a commissioner and critical-care specialist at Milton Hospital and South Shore Hospital in Weymouth, Mass., was the sole holdout in getting rid of MIPS. She pushed back against raising the proposed model's withholding rate as she feared it would push some independent medical practices to sell or close. Doctors are largely used to MIPS now, and Coombs believes the program is changing their behavior for the better in how they care for patients. "The climate has changed where physicians are coming to the table and saying what can I do in terms of bettering quality," Coombs said. Others on the panel said the fact that doctors are now getting used to MIPS doesn't mean it should be saved. "It's not a good enough reason to continue a terrible system," said Dr. Rita Redberg, a commissioner and cardiologist at the University of California at San Francisco.