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March 19, 2018

Get rid of MIPS and replace it with this, MedPAC tells Congress

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    The Medicare Payment Advisory Commission (MedPAC) on Thursday released its March 2018 report to Congress, recommending that lawmakers eliminate MACRA's Merit-based Incentive Payment System (MIPS) and replace it with a new, voluntary program intended to ease reporting burdens.

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    The report follows a MedPAC vote in January in favor of making those recommendation to Congress. 

    The 17-member commission is made up of health policy experts and providers who are tasked with making recommendations to Congress on Medicare payment and policy issues. The recommendations are not binding.


    Under MACRA's Quality Payment Program, which took effect in 2017, eligible professionals can choose from two payment tracks:

    • The Advanced Alternate Payment Model (Advanced APM) track, for clinicians who take on a significant portfolio of Advanced APMs, which include risk-based ACO models; or
    • MIPS, for providers who are reimbursed largely through fee-for-service.

    Eligible providers who participated in MIPS in 2017, which CMS deemed as a "transition" year for the program, will receive penalties or bonuses of up to 4% beginning in 2019. That percentage will increase up to 5% in payment year 2020, and rise incrementally until it reaches 9% in payment year 2022.

    MedPAC's critique of MIPS

    MedPAC in the report said that MIPS' flexibility makes it overly complex and that the model is unlikely to achieve its intended policy goal of rewarding high-quality care. MedPAC members also critiqued the degree to which MIPS:

    • Allows clinicians to decide which measures they will be evaluated on, which likely will lead clinicians to pick metrics by which they are high performers; and
    • Focuses on process measures, rather than patient outcome measures.

    In addition, MedPAC in the report emphasized the reporting burden MIPS presents and said the program lacks comprehensive measures to assess low-value care.

    Further, MedPAC said MIPS could unintentionally discourage doctors from moving into Advanced APMs by giving them an incentive to remain in fee-for-service payment programs. "The potential for positive adjustments in MIPS may be so high that staying in [fee-for-service] appears more attractive for clinicians than moving to [Advanced] APMs," the report stated. MedPAC added that the "concern is not theoretical," citing 2017 data showing that 69 practices received value modified payments that equaled about 77% of their fee-schedule revenue.

    MedPAC's proposed alternative

    To replace MIPS, MedPAC in the report calls on Congress to create a program called the Voluntary Value Program (VVP) that the committee says would reduce administrative burden on physicians.

    MedPAC Executive Director James Mathews said, "What we have in mind is a system in which physicians would not be measured on an individual basis but would come together as a group to be measured on a much smaller set of population-based outcomes measures." He added that participation "would be on a voluntary basis where all of the physicians in a multi-specialty practice could volunteer to be measured as a group, or all of the physicians on a hospital staff could voluntarily be measured as a group, or all of the members of a county medical society could say 'we want to be measured.'"

    According to the report, VVP would measure clinicians based clinical quality, patient experience, and value, and it would redesign incentives to encourage clinicians across specialties to work to improve population-based outcomes.

    MedPAC envisions that under the program, CMS would measure clinicians' performance based on claims or patient satisfaction surveys—eliminating the administrative burden on clinicians themselves. To fund the program, Medicare clinician payments would be reduced by 2%. Providers would be able to recoup the withholding or receive a bonus if they participate in the program and meet certain performance requirements. According to Mathews, MedPAC suggested 2% as the "starting point."

    According to Mathews, participants would have two main incentives to participate in the program. "One, obviously, is this program is going to provide quality bonus payments to physicians operating in fee-for-service Medicare," he said. The other is that the VVP "would provide a stepping stone to get groups of physicians who are not necessarily ready to take on financial risk to nonetheless start to become measured under the same construct that would apply under [Advanced] APMs."

    Fee schedule recommendations

    MedPAC in the report also offered recommendations on Medicare fee schedules.

    The commission recommended no payment changes for ambulatory surgical centers, long-term care hospitals, and hospices in 2019, and recommended skilled nursing facilities maintain current payment levels for 2019 and 2020.

    Mathews said, "The landscape for the fee-for-service sector this year is very consistent with overall trends observed in the last several years," noting beneficiaries have adequate access to doctors, meaning no additional change is needed.

    In addition, MedPAC recommended reducing by 5% payments to home health agencies and inpatient rehabilitation facilities in 2019.

    Telehealth recommendations

    MedPAC in the report also looked at telehealth use in Medicare. However, MedPAC said while health care organizations that use episode-based payments have flexibility for telehealth, the service is restricted under fee-for-service. Separately, Mathews said, "As a result, utilization of telehealth remains very low—less than 1% of beneficiaries were using it in 2016—and (as a result) the dollar amount is very low."

    MedPAC said it found variation in telehealth reimbursement among private plans, and noted that in most cases "private plans' cost-sharing requirements were equal to or higher than corresponding face-to-face services."

    Since MedPAC could not identify strong telehealth guidelines to adopt in Medicare, it recommended policymakers made decisions about telehealth expansion based on cost, quality, and beneficiary access to care, Mathews said (Dooley Young, Medscape, 3/16; Frieden, MedPage Today, 3/15; Commins, HealthLeaders Media, 3/15; Gregory, HealthExec, 3/15; Spanko, Skilled Nursing News, 3/15; Baxter, Home Health Care News, 3/15; MedPAC report, 3/15).

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