MIPS is, and always was, a short-term strategy. The MACRA architects designed the Merit-based Incentive Payment System as a stepping stone to participation in Advanced Alternative Payment Models (AAPMs), which they envisioned as the better avenue to improve population health and bring down costs.
The Medicare Payment Advisory Commission (MedPAC) says this stepping stone is sitting on unstable ground.
“We believe that it will not succeed as a quality improvement process and sends the wrong signals to clinicians and the delivery system in total,” said MedPAC analysts Kate Bloniarz and David Glass during a presentation to the Commissioners at their Oct. 5 public meeting.
MIPS is too complex and entails overly burdensome reporting requirements, the presenters argued. They cited a CMS estimate that the clinician cost to comply with MIPS will exceed $1 billion just in the first year. “Because of all this complexity, it is extremely unlikely that clinicians will understand their score or what they need to do to improve it,” said Glass and Bloniarz.
CMS will be limited in its ability to derive meaningful information on MIPS participants, they argued. The current design is structured to maximize clinician scores. And in a program where nearly everyone is a winner, how can Medicare “detect meaningful differences in clinician performance?"
Some concerns the policy analysts shared:
- The MIPS measures have not been proven to be associated with high-value care.
- Many of the measures are process-based, rather than outcomes-based.
- The outcomes-based measures are based on clinicians’ attestations rather than any objective measurement.
- Relatively small case sizes for an individual clinician create statistical challenges.
MedPAC Ponders ‘Voluntary Value Program’ to Replace MIPS
Rather than continue to pour resources into a flawed model, lawmakers should make participation in AAPMs more attractive (and traditional fee-for-service less attractive), the MedPAC analysts argued. “The intent of the policy option that we present here is to encourage clinicians in fee-for-service to join with other clinicians to assume responsibility for the outcomes of their patients,” they said.
They propose replacing MIPS with a new “voluntary value program,” which would be funded by withholding a portion (for example, 2%) of clinicians’ fee schedule payments. The objective would be to influence clinicians to leave the fee-for-service world and “join with other clinicians to assume responsibility for the outcomes of their patients.”
Clinicians would have three options:
- Join an AAPM and receive the value withhold back.
- Join with a “sufficiently large entity of clinicians” and potentially be eligible for a value payment on top of receiving the value withhold back.
- Make no election and lose the withhold.
To assess the performance of the participants in the value program, MedPAC would recommend a set of population-based measures in the categories of clinical quality, patient experience and value. To eliminate clinician reporting burden, the measures would be extracted from claims or centrally conducted surveys, the presenters suggested. The measures also would be aligned with those already in place for AAPMs.
Stay Calm and Carry On
Don’t throw out your MIPS strategy just yet. The road from policy discussion to final legislation is long and arduous. Now that the Commissioners have seen the bones of the policy option, they asked for more detailed recommendations for the December meeting, with a possible vote in January.
But even if one or more recommendations on MIPS are included in the March 2018 MedPAC Report to Congress, adoption is far from certain. MedPAC’s recommendations are influential, but policymakers are not obligated to follow them.
For those clinicians that currently do not have the option to participate in an AAPM, follow through on your chosen pace of participation in MIPS. Hopefully, you are on track to submit 90 days (or more) of data to qualify for a positive MIPS payment adjustment in 2019.
Meanwhile, keep your eyes on the long-term horizon for opportunities to join with other clinicians, whether in an AAPM, an ACO or a virtual group.
One option to consider is participation in a model that qualifies as a MIPS APM. For those clinicians that don’t meet the thresholds to be considered a Qualifying Participant of an AAPM, the MACRA final rule provided streamlined MIPS reporting for participants in a subset of alternative payment models, such as a Shared Savings Program or Next Generation ACO Model.
An ACO or another model that qualifies as a MIPS APM can provide an excellent bridge (and less-burdensome option) to ease the transition when participation in an AAPM becomes available.
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