How would MedPAC replace MIPS?

Bob GattyIf the Medicare Payment Advisory Commission (MedPAC) has its way with Congress, urologists and other Medicare providers will be subjected to a new payment system, replacing the Merit-based Incentive Payment System (MIPS) that was established when the sustainable growth rate formula was ditched in 2015.

On Jan. 11, MedPAC voted 14-2 to repeal and replace MIPS, one of two payment tracks physicians must follow under the Medicate Access and CHIP Reauthorization Act of 2015. The second is to participate in advanced alternative payment models (AAPMs), such as accountable care organizations.

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Under the new program recommended by MedPAC, MIPS would be replaced with a new “Voluntary Value Program” in which clinicians join a group and are compared to each other based on quality of care for patients. Physicians who do well under that scenario would receive an incentive payment.

“I applaud their recognition that the rollout and education for practices to competently follow the MIPS metrics and reporting was not straightforward and simple,” said LUGPA President Neal D. Shore, MD. “It has certainly caused a great deal of additional work for many practices and also anxiety for many clinicians.”

Dr. Shore told Urology Times that the goal of improving value-based care and quality outcomes has always been supported by LUGPA, adding that “any new improvement in a new model should strive for the same goals, but with added simplicity.”

Next: Proposal 'hard to understand'

Proposal ‘hard to understand’

However, the explanation of the new program being proposed by MedPAC-at least as described during the Jan. 11 meeting-was confusing.

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“The way MedPAC describes their proposal is hard to understand and incredibly complicated,” Dr. Shore observed.

David Glass, a principal policy analyst at MedPAC, and Kate Bloniarz, MedPAC senior analyst, recommended replacing MIPS with the Voluntary Value Program, which Bloniarz said would eliminate MIPS’ data-reporting requirements and instead leverage population-based measures from Medicare claims or “centrally conducted surveys.”

Under the Voluntary Value Program, the Centers for Medicare & Medicaid Services would withhold an unspecified amount of a physician’s pay unless he or she agreed to be evaluated on a set of population measures among a larger group of physicians. Clinicians would have the option to:

• be measured with a “sufficiently large entity” of clinicians and receive value payment

• lose withheld fee schedule money

• or participate in an AAPM.

The large entity, according to Bloniarz, could include physicians at a single hospital or in a geographic region, with an entity’s performance collectively measured using population-based measures that would fall into three categories-clinical quality, such as avoidable admissions or mortality; patient experience; and value.

“The key point,” said Bloniarz, “is that MIPS will not succeed in helping beneficiaries choose clinicians, helping clinicians change practice patterns to improve value, or helping the Medicare program to reward clinicians based on value.” Thus, she said, the commission reached consensus that MIPS should be eliminated.

“Our motivation in creating the new program is to keep a value component in traditional fee for service aligned with other value-based purchasing programs in Medicare as well as the incentives in AAPMs,” she said. “The new program would have more modest financial incentives than those possible in AAPMs and would thus act as an on-ramp for clinicians who may wish to join or form AAPMs.”

She said the new program would be budget neutral and unlikely to affect beneficiaries’ access to care, while “significantly” reducing provider burden by eliminating all Quality measure, Advancing Care Information, and Clinical Practice Improvement Activity reporting.

“Providers would incur some administrative cost in creating or joining voluntary groups, but the burden would be significantly less than current law,” she added. “Some providers would see a reduction in payments, others a modest increase.”

Dr. Shore was cautiously supportive of MedPAC’s objective of reducing administrative burdens on clinicians.

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“It’s important for us to recognize that we are all striving towards value-based care whereby outcomes are achieved at the most reasonable lowest cost,” he said.

Next: Stark Law hurdle remains

Stark Law hurdle remains

However, the objective of clinicians moving into APMs is currently difficult to attain since there are only six approved in all of medicine today and only one that is being used by a small number of urology practices. In addition, he stressed, the Stark Law, enacted some 30 years ago, complicates matters.

“We at LUGPA are working to create an APM for all urologists in the U.S., not just LUGPA members, and are submitting it to the Centers for Medicare & Medicaid Services Innovation Center for approval,” Dr. Shore said, adding that LUGPA is making a “proactive attempt to expand the accessibility of APMs for urologists.”

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But due to the Stark Law, “The challenge that remains is that incentives to follow pathways to value-based care are actually illegal,” he said, noting that LUGPA and some 25 other U.S. medical and surgical associations support legislation to modernize the Stark Law so it will not be an impediment.

“If we are ever going to get an economically fair methodology to pay clinicians to do the work that they do in evaluating and diagnosing and treating patients, and at the same time maximizing value, which is maximizing outcomes and minimizing costs, there has to be a payment method that is not so complicated and intricate that it disincentivizes practices that want to take part,” Dr. Shore said.

“I applaud MedPAC if they can come up with a pay methodology that improves the current system.”

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