Specialties to Congress: Don’t ditch MIPS

Congress has been urged to reject a proposal by the Medicare Payment Advisory Commission to ditch the fledgling Merit-based Incentive Payment System (MIPS) quality program that was established in 2015 as part of a plan to replace an outdated physician payment system that annually threatened deep cuts in provider payments.

In testimony before the House Energy and Commerce Committee’s Health Subcommittee July 26, ophthalmologist Parag Parekh, MD, representing the Alliance of Specialty Medicine, said the MIPS program “provides the only mechanism for many specialists and subspecialists to engage in federally-sponsored quality improvement and demonstrate their commitment to deliver high-value care.”

The hearing on MIPS came just a week after 11 members of the AUA met with members of Congress as part of an Alliance “fly-in” to advocate on key federal issues, including the need to retain and strengthen MIPS.

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The AUA delegation met with 18 Senate and 35 House of Representatives offices and represented urologists from Arizona, California, Louisiana, Maryland, Minnesota, New York, North Carolina, Pennsylvania, and Tennessee. In addition to stressing the need for maintaining a viable fee-for-service option for MIPS, they also expressed support for the Local Coverage Determination Clarification Act, Prior Authorization/Step Therapy reform, the U.S. Preventive Services Task Force Transparency and Accountability Act, the Resident Physician Shortage Education Act, and medical liability reform.

MIPS only option for many specialists

“No other clinician, provider, or health care professional can replace the value offered by specialty physicians,” Dr. Parekh told subcommittee members during the hearing. “To that end, MIPS must be implemented successfully and set up for long-term viability since it will be the only option for many of these specialists to engage in pay-for-performance given they will have no other option than to remain in fee-for-service.”

MIPS is one of two reimbursement tracks established by Congress under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). In the second track, physicians can participate in Advanced Alternative Payment Models (APMs) and potentially earn incentives and increased reimbursement. Although some specialty organizations, including LUGPA, are working to establish APMs for specific services, reimbursement for most services by most urologists will fall under MIPS.

Dr. Parekh noted that several Alliance member organizations working on developing APMs have been told by officials at the Center for Medicare & Medicaid Innovation that models centered on primary care were the agency’s priority.

“It is frustrating to be viewed as a costly part of the Medicare program,” said Dr. Parekh, “while simultaneously being turned away when we present proactive, innovative solutions and proposals.”

Despite that frustration, Dr. Parekh said MIPS allows specialists without suitable Advanced APM opportunities “a fair opportunity to remain in fee-for-service while continuing to measure, report, and improve performance on key areas of clinical quality improvement initiatives, and more importantly, continue to deliver high-quality care to America’s senior and disabled population.”

Starting in 2019, the quality incentive programs that existed prior to MACRA, including the Physician Quality Reporting System, Meaningful Use, and the Value-based Payment Modifier, will be combined and streamlined into a single new value-based payment system.

Utilizing tools like electronic health record technology and qualified clinical data registries, eligible professionals will transition to MIPS as the sole quality reporting system. As part of this adjustment, the penalties associated with the old incentive programs expired. Under MIPS, eligible professionals’ reimbursement will be adjusted based on four categories: Quality, Cost, Advancing Care Information, and Improvement Activities.

Each eligible clinician reporting to MIPS will be given a composite score based on performance in these categories, based on a scale of 0-100. Each year, the Department of Health and Human Services will establish a performance threshold in the form of a mean or median composite score. The score for 2018 was set at 15, rising to 30 for 2019 under the Centers for Medicare & Medicaid Services' proposed rule for revisions to the Medicare Physician Fee Schedule for calendar year 2019.

Next: Alliance supports MIPS correctionsAlliance supports MIPS corrections

Dr. Parekh said in his testimony to the subcommittee the Alliance supports technical corrections approved by Congress for the MIPS program in the Bipartisan Budget Act of 2018. They include:

• providing CMS 3 additional years of flexibility to determine the appropriate weight of the MIPS cost category based on the availability of relevant measures. “A significant amount of work remains to be done to ensure that new episode-based cost measures are developed and integrated in a way that accurately reflects the complexities of cost measurement and does not inadvertently discourage clinicians from caring for high-risk and medically complex patients,” he said.
• provisions allowing CMS to more gradually increase the MIPS performance threshold year-over-year to give physicians the opportunity to implement necessary practice changes as they gain experience and to be certain that practices with fewer resources are not negatively impacted
• elimination of Medicare Part B drugs and other items and services outside the physician fee schedule from the MIPS payment adjustments and determination of MIPS eligibility.

Nevertheless, Dr. Parekh said, additional refinements to MIPS are still needed to reduce the administrative burden and costs that must be borne by physicians.

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“A more simplistic and applicable approach will ensure not just greater clinician engagement, but more purposeful engagement,” he said, adding that the Alliance supports “practical solutions that would lessen the complexity of MIPS scoring.”

He said the Alliance supports a proposal by CMS to reduce the number of objectives and measures that physicians would report to be meaningful users of certified electronic health record technology, eliminate the “convoluted scoring construct,” and focus exclusively on a clinician’s performance on a more limited set of measures.

“If finalized,” he said, “these modifications will make a meaningful difference in the ability of many specialists to engage in the MIPS promoting interoperability performance category.”

The hearing was the committee’s fourth oversight session since passage of MACRA in 2015. Additional hearings will be held as CMS continues to implement the program.