WASHINGTON -- At a meeting of policy experts and clinicians that advise Congress on Medicare payment issues, the group reached consensus around one seemingly eternal truth: paying for quality is hard.
The group struggled to stand by its own vision of reform in the face of practical challenges.
When Congress established the Medicare Access and Chip Reauthorization Act (MACRA), the law which replaced the hated Sustainable Growth Rate formula, it changed how clinicians will be paid for the care they provide. MACRA offers physician two payment pathways: the Merit Based Incentive Program and the Advanced Alternative Payment Models (APM).
The advanced APM or A-APM track is perhaps the more complex, transformative track, but also frees physicians from the burden of hefty reporting requirements. Physicians belonging to an advanced APM receive a lump-sum 5% incentive payment based on their total fee schedule revenue from 2019 through 2024. Physicians in A-APMS also receive higher annual payment beginning in 2026.
The MIPS is the default pathway, and the one that most clinicians, approximately 600,000, will find themselves following. Under this track, clinicians' performance will be based on four key categories:
- Quality
- Cost
- Improvement Activities
- Advanced Care Information
MIPS payments while based on measures reported in 2017, will not begin until the first payment year of the program in 2019.
After receiving voluminous comments on its initial draft rule, the Centers for Medicare & Medicaid Services (CMS) issued the final MACRA rule in October. In that rule, CMS lightened many of the reporting requirements for the MIPS channel and increased the flexibility of the A-APM.s.
In the first year, for example only minimal reporting is required to avoid negative adjustments in the MIPS pathway. However, in later years, most clinicians are unlikely to receive positive updates and those that do will be small, MedPAC's technical staff predicted, because the measures are compressed or "topped out."
The quality component of MIPS focuses primarily on self-reported process measures, and staff noted that other requirements such attesting to clinical improvements and EHR use are mainly "check the box activities." Staff explained that there will likely be a large swathe of clinicians where performance can't be differentiated.
"The burden of reporting these measures may outweigh their value to the Medicare program," staff added
Or as executive director for MedPAC, saw it: "The reality of MIPS right now, is it's dead in the water."
The commission's technical staff asked the body of experts for its advice on whether and how to redesign the MIPS program.
The staff offered such options as adjusting the MIPS program so there is minimal or no clinicians reporting. It suggested the possibility of eliminating the "exceptional performance" fund of $500 million per year, which spans payment years 2019-2024.
If one of CMS's stated goal is to encourage clinicians to join A-APMs, staff questioned the reason for offering additional bonuses in the default track.
Commission members circled around the issue of whether to require quality measures and how those measures should be determined.
, of the University of Minnesota School of Public Health, put his finger on the central problem. When the measures are self-selected, he said, "we ask the provider or provider systems to tell us if the patient is getting better, and we reward them if the patient is getting better" -- and then providers are blamed for "gaming" the system.
"So you end up with data that doesn't represent actual quality and [Medicare] end up spending more than [it] should."
On the other hand, when the quality measures are overly broad and selection of quality measures isn't possible, there are also problems. An opthamologists' performance might be measured on smoking cessation, noted , of South Shore Hospital in Weymouth, Mass.
"That's not what we want in terms of being able to measure quality outcomes," she said.
Ultimately, the commission did not reach consensus on what changes it might recommend to improve the MIPS program but did identify that there is a clear need to fix it.