MedPAC will recommend repeal of MIPS

MIPS Takes a Beating at MedPAC

By Shannon Firth
MedPage Today, October 5, 2017

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on Medicare policy issues, has been set on defeating MIPS for a long time; but whether the program should be simply "repealed" or "repealed and replaced" wasn't clear at Thursday's meeting.

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.

"Our most basic concern is that the measures in MIPS have not been proven to be associated with high-value care," said (David Glass, a principal policy analyst for MedPAC).

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 end, (Commission Chairman Francis J. Crosson, MD) 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.


URGENT: Explaining MIPS; Action required

Comment by Don McCanne, M.D.
PNHP Quote of the Day, March 21, 2015

Yesterday's Quote of the Day message (March 20, 2015) 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.

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.

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.

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.



By Don McCanne, M.D.

Lost in the celebration two years ago over ending the highly flawed SGR method of updating Medicare payments was the fact that its replacement, the Merit-based Incentive Payment System (MIPS), would create an administrative nightmare while failing to achieve its goal of higher quality care at lower cost.

It’s not that the problem wasn’t recognized (see the March 2015 comment), but the policy community and the politicians just don’t get it. They make up theory, knowing that with their genius, these proposals will be phenomenal. Then they do the policy research. Well, MIPS is not working.

So what do they recommend? Let’s push physicians into the other part of the MACRA legislation, the Alternative Payment Models (APMs) - accountable care organizations and the like. After all, they have been under study for several years now and they say that they are just beginning to show slight improvements in a couple of quality measurements, and they also say that they are beginning to show a very slight downward trend in costs in some instances, unless you look at the details. In truth, they are adding to the administrative complexity with higher administrative costs that they are deliberately leaving out of their calculations, and, worse, they are increasing physician burnout.

In spite of the pessimism, they defend their position by saying that we can’t go back to the way things were. We have to start paying for value instead of volume. Yet they have failed to demonstrate two things: how you do that, and, more importantly, how a system using fee-for-service, capitation, salary, global budgeting, and rate negotiation, as appropriate, is somehow inferior to their screwball theories of value-based financing.

Of course, we offer up a well-designed single payer system as a much better alternative. And what is their response?  Single payer might be a consideration for some time in the distant future, but not now. We have to build on what is working - our administratively complex, dysfunctional, overpriced system that leaves tens of millions without appropriate care and often destitute. But they say they can fix those things by adding a public option or a Medicare buy-in, except that we will still be faced with even more administrative complexity, higher costs, too many uninsured and even greater numbers who face intolerable medical debt as the insurers place even more risk on the health care consumers (formerly known as patients).

The good news is that MIPS is going away. The bad news is that the rest of the crap stays in place and will get worse simply because we need to postpone single payer and instead build on the Affordable Care Act and its offshoots like MACRA and APMs.

Time to take a knee for single payer, or is that still a fantasy?

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