URGENT: Explaining MIPS; Action required

Summary of "SGR Repeal and Medicare Provider Payment Modernization Act"

House Committees on Energy & Commerce and Ways & Means, March 19, 2015

Yesterday's Quote of the Day:



By Don McCanne, MD

Yesterday's Quote of the Day message sounded the alarm on legislation that would replace the flawed Sustainable Growth Rate formula (SGR) for updating Medicare payments with a new Merit-based Incentive Payment System (MIPS) - legislation with strong bipartisan support that will be taken up in Congress this week and is expected to pass.

Yesterday I sent out a link to the actual legislation (minus crucial amendments, likely detrimental, that have not yet been advanced). Since few have the time to plow through the legislative language and make sense of it, I am now providing a link to the eight page summary (above).

Why this concern?

The SGR formula is considered to be flawed primarily because economic factors considered in the formula would result in inappropriate payment reductions in many of the yearly adjustments. Thus there is consensus that the formula should be repealed. However, it did provide an administratively simple process for trying to keep Medicare rates from increasing well beyond the growth in the economy. That is, there was no administrative burden placed on the providers; they merely had to accept adjustments in their payments.

The concern is over its replacement: MIPS. On reading the summary of the "SGR Repeal and Medicare Provider Payment Modernization Act," you will see that MIPS places a tremendous administrative burden on health care professionals in a health care system that is already overwhelmingly overburdened with administrative excesses. The only way to escape this additional burden is to participate in Alternative Payment Models (APMs) which, in themselves, create further significant administrative burdens (ACOs, PCMHs, etc.). MIPS is an administrative nightmare.

Some might consider the administrative excesses of MIPS to be worth it if it were to result in fair adjustments to Medicare payment rates. But you need to read the "MIPS Payment Adjustment" section of the summary.

Under the MIPS payment system, eligible professionals with higher scores will receive positive payment adjustments (and may be eligible for an additional incentive payment). We have observed repeatedly how such systems are gamed in order to receive these extra payments. The problem is that those who do not game the system, and especially those with practice situations and patient populations that make it very difficult to score higher points, will almost automatically receive performance scores below the threshold since their performances will be compared with the gamers. This will result in negative payment adjustments - reducing payments by up to nine percent. If you think SGR is unfair, MIPS robs from these hard-working professionals who are just trying to make the system work for their patients, and gives the spoils to those who likely have consultants to show them how to game the system. (Consultants? See Sec. 6 that authorizes "qualified entities" to suck more money out of our health care system by selling analyses and claims data to assist providers in their quality improvement activities., i.e., professional gamesters.)

This is serious. And it is being steamrolled through Congress right now! I consider myself an information resource, but I am not an organizer. Those who care about the future of Medicare and who do have organizational skills must immediately inform themselves on what is happening here. Then act. You cannot wait to watch the Congressional vote tally on C-Span, perhaps as early as this week. By then it will be a done deal.