Advisers Skeptical About New Medicare Doctor Pay System

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By Mindy Yochelson

Medicare’s nascent value-based measurement system may not be a good indicator of which doctors provide high-quality medical care.

Don’t expect the Merit-Based Incentive Payment System (MIPS), which began Jan. 1, to “be able to identify high- and low-value clinicians,” Catherine Bloniarz, an analyst for a federal Medicare advisory panel, said.

It won’t be useful for either beneficiaries who want to find a good doctor or for professionals who want to improve their performance, Bloniarz, a senior analyst for the Medicare Payment Advisory Commission, said. She spoke at a session on doctor payments at a March 2 MedPAC meeting.

MIPS measures medical professionals so that those who offer higher-quality care will be paid more. But MIPS has a variety of structural problems, Bloniarz said. For example, each clinician is judged by his or her own measures so scores aren’t comparable.

Recommended Changes Possible

MedPAC, which advises Congress on Medicare issues, could recommend changes to the quality measurement system, which affects hundreds of thousands of professionals.

A 2015 law, the Medicare Access and CHIP Reauthorization Act (MACRA), created a two-track system when it replaced the sustainable growth rate formula as the Part B payment methodology.

Most clinicians will start out in the MIPS track. During 2017, the first year of the program, they must choose a minimum of six measures or a medical specialty measure set out of hundreds of measures. They can receive cuts or extra money up to 4 percent of their reimbursements in 2019, based on how well they do on their measures in 2017.

Those who choose the other track, an advanced alternative payment model, will be exempt from MIPS.

Physician assistants, nurse practitioners, clinical nurse specialists and nurse anesthetists are also subject to the two-track system, along with doctors. It will be expanded to cover more Part B professionals in future years.

Problems With MIPS

The Centers for Medicare & Medicaid Services has touted that it offers professionals a wide range of MIPS measures on which to report. But Bloniarz said many are narrowly geared to specific specialties and cases. Others are “topped out,” in that overall performance is so high that the agency considers the measures no longer meaningful to collect and report.

In addition, measures involving meaningful use and clinical practice improvement activities require only attestation by clinicians “and haven’t been proven to correspond to high-value care,” she said.

Some of the commissioners agreed that MIPS is not ideal for paying professionals based on quality or nudging them to move to an alternative model.

The measurement system doesn’t distinguish between high and low performance, Commissioner Craig Samitt, an executive vice president and chief clinical officer at Anthem Inc., said during the meeting.

Another commissioner, Paul Ginsburg, the Leonard Schaeffer chair in Health Policy Studies at the Brookings Institution, said he thinks “the big mistake with MIPS was making it way too large.”

It’s also hard to measure small practices with limited available data, he said.

For large practices, the extra 4 percent performance bonus, which will increase each year, offers “big gains” for avoiding joining an alternative model, Ginsburg said.

Possible Substitute

Bloniarz outlined another possible measurement system she said offers a uniform way to compare doctors. The proposed “illustrative” system would be based on measuring groups, rather than individuals.

Each professional would contribute to a quality pool, for example a 1 percent withhold, she said. They could get it back if they join an advanced alternative payment model.

If they don’t join an alternative payment model but instead become part of either a virtual group or a group in a defined referral area, they could be subject to a cut or an addition to their Medicare payments, based on quality. Either group would have to be large enough to detect performance on measures, such as emergency department visits and readmission rates.

If they don’t join one of these groups, they lose their pool money, she said.

Same Measurements

Under the system Bloniarz outlined, Medicare would use the same measures to assess all clinicians. The cuts or bonuses would be the same for everyone in the clinician group or referral area,

“This would be a real pivot from the current MIPS program,” she said.

Professionals would be off the hook for individually reporting quality measures to Medicare, she said.

Samitt, however, wondered if such a system would offer enough incentive for providers to eventually join an alternative model.

The commissioners will revisit MIPS and other aspects of Part B payment later in 2017, commission Chairman Francis J. Crosson said.

To contact the reporter on this story: Mindy Yochelson in Washington at MYochelson@bna.com

To contact the editor responsible for this story: Kendra Casey Plank at kcasey@bna.com

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