MedPAC questions effectiveness of MACRA’s MIPS

Evidence-Based Diagnosis and Faith-Based Solutions

By Kip Sullivan JD
The Health Care Blog, April 11, 2017

It’s official: the Medicare Payment Advisory Commission (MedPAC) has at long last decided that MACRA’s MIPS (Merit-based Incentive Payment System) can’t work. MedPAC reached this decision at its January 12 and March 2, 2017 meetings.

Its principle rationale was that measuring “merit” (quality and cost) at the individual physician level, which is what MIPS requires CMS to do, is not possible. As one MedPAC staff person put it at the January meeting, “A redesign of the MIPS program should build off a clear-eyed assessment of the limit of the national Medicare program’s ability to assess clinician performance.”

But the transcripts of the January and March meetings indicate that although MedPAC is now willing to say MIPS is a mess, the commission had not reached a decision about what to do about the mess by the close of the March meeting. The commission’s challenge is obvious. As its chairman Dr. Francis Crosson put it, the issue squarely before the commission now is “whether we just … sit there and watch a dysfunctional thing unravel, or whether we try to make some recommendations which are constructive….”

In previous posts  I have argued that both parts of MACRA – the MIPS program and the Alternative Payment Model (APM) program – can’t work and that MedPAC should recommend that Congress repeal or drastically amend MACRA (the Medicare Access and CHIP Reauthorization Act).

Here is how MedPAC staffer Kate Bloniarz summarized the commission’s indictment of MIPS at the March meeting:

“To reiterate some of the issues with MIPS, first, MIPS uses hundreds of clinician-reported quality measures. Second, two of the other components of MIPS, meaningful use and clinical practice improvement activities, only require attestation by a clinician and haven’t been proven to correspond to high-value care. Third, for any given clinician, there are a relatively small number of Medicare cases, which can contribute to noisy performance. Fourth, under MIPS each clinician is judged based on their own set of measures that they reported, and so the results aren’t comparable across clinicians. In total, we don’t expect that MIPS will be able to identify high- and low-value clinicians and will not be useful for beneficiaries, clinicians, or the program.”

I applaud the commission for being so forthright. I do wonder why it took them so long to reach this conclusion. This conclusion was obvious even before MACRA was enacted, which was two years ago.



By Don McCanne, M.D.

The Medicare Payment Advisory Commission (MedPAC) is an independent federal commission that advises Congress on the administration of Medicare. It currently is evaluating the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) established by the Medicare Access and CHIP Reauthorization Act (MACRA) - the replacement for the flawed Sustainable Growth Rate (SGR) method of determining Medicare payments.

There was much celebration when SGR was eliminated by MACRA since it would have caused a drastic reduction in Medicare payment rates, but too little attention was given to the substitution in spite of warnings from knowledgeable individuals such as Kip Sullivan. Why is it a problem? As yesterday’s Quote of the Day message indicated, “desktop medicine” has displaced half of face-to-face clinical contact with patients and MIPS is destined to expand the desktop component - a major factor in exacerbating the epidemic of physician burnout. Burned-out physicians glued to desktops cannot be good for patient care.

It took forever to get rid of SGR. It is likely that MedPAC’s recommendations for MIPS and APMs will be all too feeble - recommending bland modifications that will do little to address the fundamental structural problems with the program. As the MedPAC staff member Kate Bloniarz stated, "we don’t expect that MIPS will be able to identify high- and low-value clinicians and will not be useful for beneficiaries, clinicians, or the program.”

The wheel-spinning taking place right now is mostly about replacing volume with value when actual efforts have been quite unproductive. It would be far better to concentrate on reforming our financing system with a well designed single payer national health program - an improved Medicare for all. Once we get the financing right, we can concentrate on much more rational methods of fine tuning that financing.