Not so voluntary: MedPAC’s MIPS replacement analyzed Not so voluntary: MedPAC’s MIPS replacement analyzed
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Not so voluntary: MedPAC’s MIPS replacement analyzed

Grant Huang, CPC, CPMA
Director of Content

You wouldn’t have to worry about the Merit-based Incentive Payment System (MIPS) if a top Congressional advisory group and the President of the United States had their way, but would you actually want the proposed replacement for MIPS?

Remember: The Medicare Payment Advisory Commission (MedPAC) is an independent federal board that regularly advises Congress on how best to run the Medicare program, and its members voted 14-2 last year to get rid of MIPS and replace it with a “voluntary” quality reporting program. However, a closer look at their replacement program, which is unnamed (the Committee’s report simply refers to it as a “potential redesign of MIPS”), shows it could be just as impactful to practices’ bottom line if adopted.

Created in 1997, MedPAC has no authority to create law, but regularly issues widely-read reports to Congress with recommendations on various aspects of administering Medicare. Lawmakers from both parties often cite MedPAC’s recommendations during the legislative process, but are under no obligation to follow any of them.

In this article, we’ll take a closer look at MedPAC’s proposed redesign, which could influence future legislation even though Congress has thus far shown little interest in repealing MIPS. As the product of a rare bipartisan healthcare bill with major implications (MIPS was part of the Medicare Access and CHIP Reauthorization Act or MACRA), repealing it would require consensus in one of the most divided legislative eras in history.

Is MedPAC’s ‘redesigned’ MIPS really voluntary?

Before it voted to recommend that Congress repeal MIPS, MedPAC published a report in June 2017 which laid out the broad strokes of a program that would replace MIPS.

“Redesigning MIPS requires considering the current state of performance measurement and realistically setting goals for a national value-based purchasing program for clinicians,” MedPAC states in the report. “The current MIPS system is designed primarily to measure basic standards of care and processes—not outcomes. In addition, it imposes burdens on clinicians and CMS that outweigh any potential benefit because the measures used for assessing quality, the ACI category, clinical practice improvement activities, and costs are unlikely to capture true value.”

Its redesign would focus on improving clinical measurements and tying patient outcomes more directly to performance on those measures. MedPAC also stressed that its redesign would reduce the burden of participation on providers and would be “voluntary” – two elements that have gotten the most attention, particularly from providers.

But MedPAC’s replacement program wouldn’t be truly voluntary, an analysis by The OrthoActivist shows. Here’s why:

  • It would implement an automatic, mandatory withholding of a portion of Medicare fee-for-service payments and use that money to fund a quality pool.
  • The proposed mechanism for the withholding would be a global Part B payment reduction that “is sufficiently large to incentivize quality improvement.”
  • Providers could then make one of four decisions:
    • Do nothing (the default option) and simply lose a portion of payments based on the withheld payment percentage;
    • Join an Advanced Alternative Payment Model (A-APM) and immediately receive the withheld monies;
    • Join a group of clinicians choosing to report quality measures, participate, and receive the withheld monies, with a chance of earning an additional quality payment based on performance (the option most akin to MIPS participation, under a reporting option that is identical to MIPS’ “virtual groups,”);
    • Allow CMS to measure their performance as part of a local area or market area, which could be based on geography, patient population, or both, and receive the withheld monies, with a chance of earning an additional quality payment based on performance.

Thus the MIPS redesign would automatically reduce Medicare payments without provider action, which you must volunteer to avoid a pay cut.

No manual reporting required

While it’s debatable just how voluntary the MIPS redesign would be, MedPAC does include a major provider benefit in the form of converting all quality measures to population measures. These are measures which look at the effect of provider care at a population level rather than an episodic level; MedPAC offers some examples such as:

  • Potentially preventable admissions and emergency department visits
  • Mortality and readmission rates after inpatient hospital stays
  • Healthy days at home
  • Patient experience
  • Rates of low-value care
  • Relative resource use

“MIPS, as designed, is unlikely to clearly identify high value or low-value clinicians and hence may be of limited utility for beneficiaries (in selecting high-value clinicians), for clinicians themselves (in understanding their performance and what to do to improve), or for the Medicare program (in adjusting payments based on value),” MedPAC writes in the report.

These population measures, on the other hand, would be collected by CMS via claims without any manual reporting action by providers. This alone would make the redesigned MIPS much easier administratively, though MedPAC admits that switching from measuring individual provider performance (or group performance) and using a reporting process that takes away provider measure selection could make providers feel less in control.

Is the redesign purely theoretical?

While MedPAC’s redesign is a roadmap and not a detailed regulatory document, does it have any chance of being enacted? “It’s become more likely now that the President has indicated a desire to do away with reporting of quality measures under MIPS,” says Bradley Coffey, AAOE’s Manager of Government Affairs. “But, whether that support from the White House translates into congressional action is unclear at this point.” Other stakeholder groups, such as the AMA, were critical of MedPAC’s vote against MIPS even as they acknowledged that MIPS wasn’t perfect.

The Commission acknowledged these concerns in the report, writing that: “There are drawbacks to such a redesign. CMS is already years down the path of establishing a comprehensive quality-data reporting system that uses multiple methods of data reporting and extraction … Switching gears at this point would require significant time and effort for CMS. In addition, clinicians and other providers in the broader health care delivery system have spent significant time and resources building systems and operations that feed information to CMS using this framework.”

But MedPAC sticks by its belief that population-based measures would provide more valuable information while reducing the reporting burden on practices, even though its program wouldn’t be especially voluntary with an automatic payment withholding mechanism.

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