“[T]his is tough. I don’t know how to proceed…. Lord help the staff who must bring all this together.”
That was how Dr. Francis Crosson, chairman of the Medicare Payment Advisory Commission (MedPAC), reacted to the commission’s baffling discussion at its January 11 meeting moments before it voted 14-2 to replace the Merit-based Incentive Payment System (MIPS) with something called the “voluntary value program” (VVP) (pp. 167-169 of the transcript ). MedPAC’s staff must now summarize the January 11 discussion and prepare a report for inclusion in MedPAC’s March 2018 report to Congress.
MIPS is a pay-for-performance (P4P) scheme imposed on the traditional fee-for-service Medicare program by an act of Congress known as MACRA. MIPS requires that CMS measure performance on cost and quality at the level of the individual doctor, something MedPAC recently acknowledged can’t be done after spending 13 years claiming it could be done.
The portion of the commission’s January 11 discussion that focused on the repeal of MIPS was not hard to understand. The commissioners agreed that MIPS cannot work for multiple reasons, the most important being that the pools of patients treated by individual doctors are too small to permit accurate measurement of cost and quality. “MIPS will not succeed in helping beneficiaries choose clinicians, helping clinicians … improve value, or helping the Medicare program to reward clinicians based on value,” explained MedPAC staffer Kate Bloniarz. (pp. 116-117) Only one of the 16 commissioners present (Dr. Alice Coombs) disagreed with that statement.
Zen and the art of summarizing doubt
It was the commissioners’ discussion about what to replace MIPS with that will be very difficult to summarize. That’s because the discussion consisted largely of expressions of doubt about the VVP, which is essentially a proposal that all doctors who treat Medicare patients either join a “group” (aka ACO) or lose 2 percent of their Medicare payments. The discussion, which followed a vague opening presentation by two MedPAC staff members, consisted of numerous questions posed to the staff that neither the staff nor Dr. Crosson could answer. Because so many issues remained unresolved, ten of the 16 commissioners (one was absent) expressed reservations about voting for the VVP. How does the staff or anyone else summarize a discussion like that? How does the staff explain why the commission voted to recommend the VVP to Congress when a majority of commissioners have multiple concerns about it?Continue reading…
In the 2018 proposed Medicare Access and CHIP Reauthorization Act’s (MACRA’s) rule, published earlier this year, HHS has again proposed to exclude two-thirds of physicians, or 900,000, from participation in the Merit-based Incentive Payment System (MIPS). MIPS was created under 2015 MACRA legislation to incent financially Medicare physicians and other Medicare Part B clinicians to improve care quality and reduce Medicare spending growth. HHS is choosing to exclude smaller-sized physician practices because, it is believed, MIPS reporting requirements place too high a burden on less resourced practices. However, MACRA legislation includes a “virtual group” provision that allows for solo and small group practices to partner in meeting MIPS reporting requirements. For technical reasons the Centers for Medicare and Medicaid Services (CMS) was delayed in implementing the provision. The first year in which providers can participate in MIPS as a virtual group will be 2018. Designed correctly, virtual groups offer substantial advantages that include greater MIPS participation, more competitiveness, higher financial reward and more opportunity for small practices to keep their independence.
At its January 12, 2017 meeting, the Medicare Payment Advisory Commission (MedPAC) made it clear they had reached the conclusion that the Merit-based Incentive Payment System (MIPS) cannot work (see my last post ). MIPS is the larger of the two programs within MACRA; the Alternative Payment Model (APM) program is the other. The commission’s primary rationale for its conclusion about MIPS is that it’s not possible to measure physician “merit” (cost and quality) at the individual physician level.
But rather than recommend that Congress repeal MACRA (the Medicare Access and CHIP Reauthorization Act), MedPAC decided to try to fix it. At the January and March 2 meetings, the commissioners discussed a staff proposal to amend MIPS substantially and to tweak the APM program. Those discussions went nowhere.
I give MedPAC credit for finally stating unequivocally that MIPS cannot work. But MedPAC should never have volunteered to fix MACRA. It can’t be done. By proposing modest amendments to MACRA and thereby implying it’s fixable, they stepped into an intellectual tar pit. I will illuminate this tar pit by describing the commission’s unproductive discussion about the staff’s proposed amendments to MACRA. To give you a sneak preview of what that discussion was like, I give you two excerpts from the transcript of the January meeting:
With all the machinations over ACA repeal and replace, the new law that makes big changes in the way the federal government pays doctors—the Medicare Access and CHIP Reauthorization Act, or MACRA—hasn’t garnered much attention lately.
But doctors nationwide are sure thinking about it. That includes many of the regular commentators on THCB. I think it’s accurate to say that most of them have been highly critical of MACRA since the law was enacted in April 2015, and even after it was significantly amended late last year to address physician complaints. (See, for example, Kip Sullivan’s most recent post here.)
The law’s main provisions kicked in on Jan. 1, 2017, with 2017 being the first performance-reporting year, affecting payment in 2019.
As Kip and many others have noted, some parts of MACRA are weakly designed and both the law and regulations implementing it make some big assumptions. Excerpts from one section of the policy brief are below. The whole brief can be had at the link above. If you are well versed in MACRA, you can skip to the section titled “What’s the Debate?
Is the overall design coherent and workable?
Major special-interest groups, including those representing physicians, industry, and consumers and patients, supported MACRA’s intent and the general framework of the regulations through three comment periods.
However, almost all groups sought changes and raised questions. CMS’s final revisions were most responsive to physician groups, which were insistent on an easier path and more flexibility for doctors in the initial years of the program.
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” (pp. 235-236 of the transcript of the morning session of the January 12, 2017 meeting).
I just finished reading the 962-page MACRA rule CMS released late in April. I was prepared for the mind-numbing complexity of the document. What I was not prepared for was CMS’s glib treatment of two fundamental issues: The woeful inaccuracy of the scores CMS will use to punish and reward doctors, and the cost to doctors of participating in ACOs, “medical homes” and other “alternative payment models” (APMs)
These are not peripheral issues. If CMS dishes out financial rewards and punishments based on inaccurate data, MACRA will, at best, have no impact on cost and quality and may well have a negative effect. The second problem – the high cost of setting up and running APMs – may not be as lethal as the inaccurate-data problem, but at minimum it will reduce physician participation in APMs and, therefore, the already slim probability that APMs will reduce Medicare costs and improve quality.
In this comment and two more to come, I will review both of these problems and CMS’s what-me-worry attitude toward them. I begin with a jaw-dropping example of CMS’s reckless indifference to its inability to measure physician “merit” accurately.
What does the Medicare Access and CHIP Reauthorization Act (MACRA), signed into law in 2015, mean for healthcare organizations and providers? At HIMSS 2016, the CMS Center for Clinical Standards and Quality Director, Kate Goodrich, MD, stated MACRA’s goal: “to have a single, unified program with flexibility. The new Merit-Based Incentive Payment System (MIPS) will offer that flexibility and not be a one-size fits all program. The new rule will reimburse physicians based on four factors.”
Health systems are still waiting for additional details about the “four factors” Goodrich mentioned (listed in this article under “MIPS”) or how CMS will reward providers for delivering better care. We’re aware of MACRA’s general structure, but still waiting for clearly defined rules and regulations. Until then, it will be difficult to evaluate this new law.
Even though health systems are currently in a waiting period for clarifying details about the proposed MACRA regulations (with major impacts in 2019), MACRA’s base year will likely be 2017—and 2017 is just around the corner. This article provides an overview of MACRA and guidance about what health systems should do to prepare for MACRA now.
Nearly a year ago President Obama signed the Medicare Access and CHIP Reauthorization Act (MACRA) into law. MACRA, among other things, repeals the 1997 Balanced Budget Act’s Sustainable Growth Rate (SGR) formula for calculating annual updates to Medicare Part B physician and other eligible professionals’ payment rates.1 The bill received overwhelming support in both the House and Senate, only 45 out of 529 total votes cast opposed the bill despite the fact the legislation is estimated to add $141 billion to the federal deficit by 2025.2 Support for the legislation can, in part, be attributed to the Congress having grown tired of rescinding SGR mandated payment cuts or passing nearly 20 “doc fix” “patches,” over 18 years. Presently, Medicare physicians are awaiting CMS’s proposed rule that will define how the agency intends to implement the six sections of MACRA Title I, or how the agency will annually update physician performance beginning in 2019 based on the use of the law’s Merit-Based Incentive Payment System (MIPS) and its Alternative Payment Models (APMs) pathway. The proposed rule, expected to be published in the next few weeks, is highly anticipated because the rewards and penalties under either MIPS and APMs can be significant.
It’s done. Congress on April 14 passed and the president signed into law a bill that terminates one of the most egregious and silliest examples of dysfunctional government in recent years—the so-called “sustainable growth rate” (SGR) formula for doctors’ fees under Medicare.
First, a round of applause for bipartisan agreement—however obvious it was that had to happen in this case. The vote in the house was 392-37. In the Senate, it was 92-8.
Praise is also in order for enacting two more years of funding for the Children’s Health Insurance Program and $7.2 billion in new funding over two years for community health centers, a program that was expanded under the Affordable Care Act and serves low-income families. There’s also welcome help for low-income Medicare beneficiaries and rural hospitals.
But the main thrust of the law is to kill one (failed) program that adjusted doctors’ fees under Medicare and create a new and hopefully better one.