Most MedPAC Members Happy to Ditch MIPS Program

The lone holdout on ditching the program noted that eliminating MIPS and replacing it with the Voluntary Value Program (VVP) could cause more physicians to rush to become hospital employees.

This article first appeared December 08, 2017 on Medpage Today.

By Joyce Frieden

WASHINGTON -- Momentum appeared to be growing on Thursday for a proposal from the Medicare Payment Advisory Commission (MedPAC) to get rid of the Merit-Based Incentive Payment System (MIPS) for reimbursing physicians who see Medicare patients.

"We need to act on this now," MedPAC staff member Kate Bloniarz told the commissioners. She added that clinicians will start reporting their quality data this year for reimbursement in 2019. "The longer the payments go out, the more there will be an established [group] of clinicians receiving really high payment adjustments who will resist changes to the program."

MIPS, which was enacted as part of the Medicare Access and CHIP Reauthorization Act (MACRA), 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).

Bloniarz listed a number of concerns with MIPS, including:

• It gives physicians a heavy reporting burden, which was estimated at more than $1 billion for the first year of the program
• Much of the information reported isn't meaningful, partly due to small sample sizes and the fact that only a few quality measures assess meaningful outcomes, she said. In addition, each clinician is scored on different measures representing different levels of effort, "so it's not comparable across clinicians, but CMS will move substantial funds around each year based on these non-comparable scores"
• CMS has exempted more clinicians from MIPS in 2018 than are required to participate, and has special rules for small and rural clinicians. As a result of these and other CMS actions, in years 3 and later, "small differences in [scores] will be blown up into potentially massive differences in payment adjustments. The system is inequitable ... It won't move clinicians and the Medicare program toward high-value care"

Commission staff members are recommending replacing MIPS with a new program called the Voluntary Value Program (VVP). Under the VVP proposal, all clinicians would see a portion of their fee schedule dollars withheld and lumped into a pool. Clinicians could then be measured with a group of other doctors -- based on population-based outcomes, patient experience, and cost -- to be eligible for value-based incentive payments from the pool.

Otherwise, they could decide to participate in an advanced alternative payment model (AAPM) program -- an option they have under the current reimbursement system, in which groups of physicians and hospitals can earn a bonus of up to 5%, based on patient outcomes, in exchange for taking on financial risk. If they chose neither of those options, they would lose all the money withheld.

Most commission members agreed with the staff's suggestions. "I strongly support the recommendation," said commissioner Bruce Pyenson, of the Milliman consulting firm, in New York City. "The virtue of this approach ... is that it's something the rest of the healthcare plans could use ... Here's a way where the Medicare program can actually make things easier for the rest of the healthcare system."

Pat Wang, JD, of the Healthfirst insurance plan in New York City, also liked the recommendation, but cautioned that "lots of important details" need to be worked out with the VVP, including attribution of patients and risk adjustment. "But I do support it because I think it's directionally better and has the potential to be a better system."

Commissioner Kathy Buto also supported the recommendation, "but I think the weak link is that there are not enough population-based measures," she said. "I don't think we have a good grasp of the complexity of what's going to be needed." She suggested eliminating MIPS but giving CMS time to come up with better population-based quality measures.

The lone holdout on ditching the program was commissioner Alice Coombs, MD, of South Shore Hospital in Weymouth, Massachusetts, who noted that eliminating MIPS and replacing it with VVP could cause more physicians to rush to become hospital employees. "If the withhold is higher ... I think people will go to the nearest hospital and say, 'I want to jump on your wagon'" so they don't have to worry about complying with the VVP and possibly threatening the viability of their practice, she said.

"I haven't heard large physician groups say it's a great idea. Initially, the physicians I talk to have a positive reaction to getting rid of MIPS, but when I tell them we're [thinking about] going to a VVP, then they say, 'Wow, I will be judged on something I have absolutely no control over.'"

Although some of the process measures required by MIPS may not be useful, "there are a lot of process measures you can check off that can cue you into something else [that's wrong]," she continued. "At least physicians are now coming to the table and saying, 'What can I do in the quality realm?' And I think patients are better for it."

In addition, some doctors don't have geographic access to AAPMs that they can readily join, "and many doctors caring for minority patients are faced with the fact that they have higher-risk patients who are not risk-adjusted well," she said.

Commission chair Francis Crosson, MD, of Palo Alto, California, emphasized that looking at a VVP "in no way should be read that we don't believe in the value of process measures. We certainly do ... We're just saying as a mechanism at a national level to move money" to individual physicians [it] isn't a good idea.