MedPAC Votes a Resounding "No" to MIPS, Recommends Voluntary Value Program

The Medicare Payment Advisory Commission (MedPAC) conducted a formal vote that recommend repealing and replacing CMS’ Merit-based Incentive Payment System (MIPS), 1 of 2 reimbursement tracks that physicians can enroll in under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

With a 14-2 vote, the committee called for MIPS to be replaced with a Voluntary Value Program (VVP), where 2% of clinicians' payment would be withheld if they were not enrolled in an advanced alternative payment model (A-APM) or chose to be evaluated on certain population-based measures.

In their presentation, the MedPAC committee members said that MIPS—an individual-level payment adjustment—is burdensome and inequitable, responsible for $1 billion in clinician reporting burden in 2017 alone. They also raised questions about the meaningfulness of quality outcomes measures recommended under MIPS, in addition to raising questions about other categories that physician practices will be evaluated on, including advancing care information and clinical practice improvement activities. The committee also disagrees with the fact that physicians can choose the measures that they will be evaluated on, because “non-comparable scores” will be the basis of payment allocation across clinicians.

The presentation states that the inequitable, burdensome system of MIPS “will not improve care for beneficiaries nor move the Medicare program and clinicians towards high-value care.”

Researchers have voiced concerns about how MIPS is structured, with an editorial published in the Annals of Internal Medicine by Teryl K. Nuckols, MD, from Cedars Sinai Medical Center, which discussed how physicians have the opportunity to game the system by selecting healthier patients to report on or excluding physicians in their practice who have a low score. He notes in his editorial, “Clinicians may be deterred not only from treating patients who are sicker or less adherent to treatment recommendations but also from affiliating with clinicians who treat such patients, which could exacerbate socioeconomic disparities in care.”

Scoring for physicians in the MIPS track placed a higher weightage (60%) on care quality for 2017, while cost was at 0%. However, this was expected to shift by 2019, with each measure given a 30% weightage. Providers had the option of waiving participation in 2017, but would lose 4% of their payment for the year, which could be avoided by reporting on at least 1 of the 4 metrics.

MedPAC members want a complete elimination of MIPS, however, and they recommend replacing it with VVP, which, according to the presentation, would encourage movement toward A-APMs and eliminate clinical measure reporting. The committee shared the following key points about the new structure:

• Population-based, claims-calculated, and patient-surveyed measures
• Voluntary groups of physicians would be large enough to support population measures
• Value payment would be based on voluntary group performance

The claims-based tracking by CMS would eliminate concerns over physician reporting bias. Similar to MIPS, however, physicians who choose not to participate in any APM would be penalized by having a percentage of their Medicare payments withheld.