Commission votes 14-2 to fold Merit-based Incentive Payment System.
This article first appeared January 11, 2018 on Medpage Today.
By Shannon Firth
WASHINGTON -- The Medicare Payment Advisory Commission (MedPAC) voted 14-2 to in favor of killing the Merit-based Incentive Payment System (MIPS) and replacing it with an alternative model of reimbursement on Thursday.
While the numbers appear to signal a strong consensus for the proposed recommendations, a handful of members who voted to nix the program expressed hesitation.
"I'm not afraid to make an unpopular decision, but I want to make sure we do something constructive," that sends the right message and is headed in "the right direction," said Commissioner Warner Thomas, of Ochsner Health System in New Orleans.
Thomas worried that if commissioners aren't careful, the alternative model -- the Voluntary Value Program -- meant to replace the MIPS could repeat some of its mistakes.
Commissioner Kathy Buto, MPA, of Arlington, Virginia, said that after listening to her colleagues, she wasn't "totally comfortable" with the VVP. She noted that the recommendations should focus on "uncertainties" such as what percentage should be withheld for fee schedule payments, and how to control for economic disparities.
But as was pointed out by Commissioner Dana Gelb Safran, ScD, of Blue Cross Blue Shield of Massachusetts in Boston, who also voted in support of the recommendations, "I don't hear a single commissioner saying we must preserve MIPS."
On the other hand, the panel had previously ruled out a straight "repeal" of MIPS. The decision was between two models: MIPS and the VVP.
MIPS combines parts of the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier, and Meaningful Use into one single program based on quality, resource use, and clinical practice improvement. Under MIPS, doctors earn a payment adjustment based on evidence-based and practice-specific quality data that they report to the Centers for Medicare & Medicaid Services (CMS).
The VVP involves gutting the MIPS and replacing it with a design that includes an across-the-board withhold for all fee schedule payments. (In the past, MedPAC's staff suggested a 2% withhold as an example, but that percentage has not definitively been decided.)
Clinicians then choose to either join a voluntary group or to engage in an advanced Alternative Payment Model (A-APM) to receive the withheld amount.
Those who do neither, lose their withhold.
Clinicians who join voluntary groups will be assessed based on the performance of the group using population-based measures related to clinical quality, patient experience, and value.
Two commissioners voted squarely against these recommendations: Alice Coombs, MD, of South Shore Hospital in Weymouth, Massachusetts, and David Nerenz, PhD, of Henry Ford Health System in Detroit, Michigan.
"I agree with the sentiment that MIPS has a lot of problems, but my major objection is the timing," said Coombs.
The group had shifted from "maybe tweaking" the program to "getting rid of it" over 12 months. In 2015, MedPAC didn't say a word about eliminating MIPS, she noted.
A change this big requires infrastructure and cultural adaptation, and the commission's alternative model and basic strategy provides neither, she argued.
MedPAC Chairman Francis "Jay" Crosson of Palo Alto, California, said he wished the commission had made its recommendation sooner, but it had spent much time investigating whether the program could be modified.
"We came to the conclusion that it's simply not fixable," he said.
Nerenz voted against recommending to replace MIPS with the VVP because he doesn't view the program as voluntary. Every physician would see a percentage of Medicare payments withheld regardless of whether they participated in it, he said, likening it to a sorority or fraternity "rush."
The "cool people," those who have good performance because their patients are "educated" and "take good care of themselves," will form groups of their own, while anyone not included in "the cool people's rush process" will be left out of the program, he said.
"It's not enough to say you want to be in a [voluntary group]; you have to be accepted," he added.
Nerenz also worried that the model would rely on CMS to adjust for social and economic risk factors, which is something the agency has been reluctant to do in the past.
"I do not have confidence that that will go well," he said. "Poor people will be hurt."
Crosson took issue with the idea that the model would generate exclusive groups and leave the rest of physicians "with their nose pressed against the glass."
While it's possible for some groups to selectively choose members, other groups might consist of a hospital's medical staff or a county medical society.
MedPAC, whose 16 members include physicians, healthcare executives, and other policy experts charged with advising the Department of Health and Human Services on Medicare policy issues, has been questioning the worth of MIPS since last January.
In its June report, the commission wrote, "as presently designed, [MIPS] is unlikely to help beneficiaries choose clinicians, help clinicians change practice patterns to improve value, or help the Medicare program reward clinicians based on value."
Today's recommendations will be written into MedPAC's March report.
Anders Gilberg, vice president of government affairs for the Medical Group Management Association (MGMA), said in a statement that his group "shares MedPAC's concern that aspects of the current MIPS program are unduly burdensome and impede patient-centered care and innovation."
"However," he continued, "we believe its recommendation to eliminate the program fails to adequately address the problem and does not reflect the current value-based landscape. MedPAC's alternative that would conscript physician groups into virtual groups and evaluate them on broad claims-based measures is inconsistent with the Congressional intent in MACRA to put physicians in the driver's seat of Medicare's transition from volume to value."