Among the items addressed in The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was the way the U.S. government pays physicians. The law sought to replace the fee-for-service payment system with one that rewards physicians for the quality and effectiveness of the care they provide.
The payment mechanism that applies to most physicians under MACRA is the Merit-based Incentive Payment System, or MIPS. According to the government’s MIPS website, “MIPS was designed to tie payments to quality and cost efficient care, drive improvement in care processes and health outcomes, increase the use of healthcare information, and reduce the cost of care.”
Under MIPS, payment to physicians is based on their scores in four performance categories:
- Quality: Calculated using performance measures created by the Center for Medicare and Medicaid Services. Physicians choose six measures most appropriate for their practice.
- Advancing Care Information: This is an updated version of Meaningful Use. It measures physicians’ productive use of the healthcare information they create, which is done by sharing the information — such as test results, visit summaries and therapeutic plans — with patients or other clinicians.
- Improvement Activities: An assessment of the ways in which a physician improves care processes, enhances patient engagement and increases access to care. Physicians choose the activities on which they are judged. Choices include enhancing care coordination and sharing decision making with patients.
- Cost: Calculated by the CMS based on Medicare claims.
MIPS went into effect in 2019. Clinicians who treated few Medicare patients will be exempt from MIPS. Doctors who are compensated by what the CMS classifies as Alternative Payment Methods (APMs), such as Accountable Care Organizations and the Medicare Shared Savings Program, are, strictly speaking, exempt from MIPS. However, they will be subject to quality measures very similar to those under MIPS.
MIPS, however, is getting pushback.
The Medicare Payment Advisory Commission (MedPAC), a federal agency that provides Congress with analysis and policy advice on Medicare, called for MIPS to be scrapped, saying it is too complex and that it doesn’t address issues of its predecessor, Medicare’s Value-Based Payment Modifier Program.
The Modifier Program measured physicians using criteria such as spending and outcomes with the stated aim of increasing the value of their care. However, according to an article from Fierce Healthcare, the system “shifted money away from doctors who treated sicker, poorer patients to pay bonuses that rewarded practices that treated richer, healthier patients.”
Citing a study published in the Annals of Internal Medicine, MedPAC argued that MIPS is a burden on physicians and fails to improve care or reward deserving physicians.
“We’ve gone headlong into pay for performance despite study after study showing that it doesn’t improve quality or lower overall spending. We should expect more of the same from the MIPS because the MIPS is more of the same,” said Dr. J. Michael McWilliams, one of the study’s authors.
MIPS, though, has plenty of defenders. While not denying its failings, many in the medical community argue that it’s too far along in the process to simply scrap MIPS, and that tweaks could make the system’s reporting fairer and less of a burden to providers.
Another concern is the lack of available details on the proposed replacement for MIPS, the Voluntary Value Program (VVP).
Under VVP, providers volunteer to be measured as part of a self-organized group and would be eligible for value-based payments based on the group’s performance. Performance is based on metrics such as hospital readmissions and patient experience scores.
“Now is not the time to scrap MIPS,” said Nancy Foster of the American Hospital Association. “MACRA passed with strong bipartisan support, and the VVP is not a compelling alternative,” Foster said, adding that “hospitals and their clinician partners have made significant investments of time, effort, and other resources to prepare for the new program.”
