WASHINGTON -- Health policy experts sometimes battle for consensus over payment issues, but when it comes to the new way of paying most doctors under Medicare, one group reached near-unanimous agreement: Scrap it.
The Merit-based Incentive Payment System (MIPS) should be spiked, virtually all members of the Medicare Payment Advisory Commission (MedPAC) said during a meeting on Thursday morning.
MedPAC, whose 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on Medicare policy issues, has been set on defeating MIPS for a long time; but whether the program should be simply "repealed" or "repealed and replaced" wasn't clear at Thursday's meeting.
At the start of the meeting, MedPAC's analysts addressed the challenges with the MIPS program and proposed a potential alternative.
The Problem with MIPS
The MIPS program is one of two payment vehicles created as a result of the the Medicare Access and CHIP Reauthorization Act (MACRA) -- which replaced the almost universally despised Sustainable Growth Rate (SGR) formula. The other payment pathway consists of an array of advanced Alternative Payment Models (APMs), which weren't discussed in any detail at the meeting.
The main problem with the MIPS program, as MedPAC's analysts see it, is that MIPS won't achieve the policy goals that it's designed to achieve.
The flexibility of the program -- the various options for how physicians can report measures and the broad exemptions for certain types of clinicians -- has made it overly complex. There are also statistical challenges that stem from trying to develop individual-level performance scores, due to the relatively small case sizes for some providers.
"Everyone will seem to have high performance when in fact many of the measures are topped out or appear to be topped out ... and that will limit Medicare's ability to detect meaningful differences in clinician performance," said David Glass, a principal policy analyst for MedPAC.
In the end, Medicare gives clinicians a score based on their performance and either raises or reduces their Medicare payment based on that score, but for all the reasons Glass mentioned, he believes it is "extremely unlikely that physicians will understand their score or what they need to do to improve it."
"Our most basic concern is that the measures in MIPS have not been proven to be associated with high-value care," he said.
Alternative Proposed
Glass and MedPAC senior analyst Kate Bloniarz suggested an alternative policy approach that leverages population-based measures.
The Voluntary Value Program, as they've dubbed the alternative, would get rid of the MIPS program and all three types of reporting requirements -- Advancing Care Information (ACI), Clinical Practice Improvement Activities (CPIA), and quality measures -- and scrap CMS support for Electronic Health Records reporting.
In the new model, all clinicians would see a portion of their fee schedule dollars withheld, which would be lumped into a pool -- for example 2%, though analysts stressed the percent amount had not been decided.
Clinicians would then have three options:
- Choose to be measured with a "sufficiently large entity" of clinicians and be eligible for value payments
- Choose to participate in an advanced APM model
- Lose the withheld fee schedule dollars
In the first option, the "sufficiently large entity" could be those physicians affiliated with a single hospital or one geographic area, she said.
"An entity's performance would then be collectively measured using a set of population-based measures," Bloniarz added.
A limitation of the model is that entities must be "sufficiently large" in order to have "statistically detectable performance on the population based measures."
In the Voluntary Value Program, measures could potentially fall under three categories: clinical quality, patient experience, and value. For example, a clinical quality measure might include mortality or avoidable admissions.
Unlike the MIPS program, all of the measures could be pulled from Medicare claims data or "centrally conducted surveys" avoiding the clinician reporting burden, Bloniarz explained.
Repeal and Replace?
Most members of the commission expressed support for the new model or at least felt it was a good start.
One new commissioner, David Grabowski, PhD, of Harvard ľֱ School in Boston, said he favored having a replacement, but he worried that some physicians, particularly those in rural areas, or those treating dual eligible patients (enrollees in both Medicare and Medicaid) might be left out. He stressed that incorporating proper risk adjustment mechanisms into the measurement process would be critical.
Paul Ginsburg, PhD, of the Brookings Institution, also supported a repeal-and-replace strategy.
"My sense is that the politicians don't want to do nothing. They want to do something," he said.
However, several commissioners were more hesitant, asking whether replacing the MIPS program was necessary.
"Are we creating something that is so close to the advanced APM structure that it's almost not worth it?" asked Dana Gelb Safran, ScD, of Blue Cross Blue Shield of Massachusetts.
Gelb Safran suggested that if the commission does choose to recommend an alternative, distinctions between it and the APMs would need to be clear. She also wondered aloud whether with these new entities would revive some of the challenges of the old SGR formula.
The challenge with the SGR was that individuals weren't truly accountable to each other even though they were lumped together, she explained.
"That really undercuts the desire to behave in the way that the incentives should make them behave because somebody else could kill their incentive, so why bother."
Craig Samitt, MD, MBA of Anthem in Indianapolis, said he would favor a repeal-only approach, based on the replacement model he'd seen that day.
"If a replacement is a voluntary model that would allow us to keep practicing healthcare the way we've been practicing, then that replacement is not a good replacement," Samitt said.
MedPAC member Kathy Buto, MPA, of Arlington, Virginia, suggested another idea: repeal the MIPS program, but continue to withhold the funds from the clinicians who aren't participating in the advanced APMs. Then use those dollars to reward APM performance.
"I would actually increase the penalty and make it less attractive to stay in MIPS regardless," she said.
Commission Chairman Francis J. Crosson, MD, joked that he would be happy to escort Buto from the meeting after it adjourned -- implying her idea might be dangerously unpopular with physicians.
In the end, Crosson determined that MedPAC's technical team would return to the group with draft recommendations for repealing the MIPS program and offer two options: a voluntary replacement program similar to the one discussed at Thursday's meeting with some revisions, and suggestions on how to make the advanced Alternative Payment Models more accessible for physicians.
The commission could then decide whether to recommend one or both options to HHS.