The proposal from MedPAC would replace MIPS with a voluntary program, but analysts say it’s hard to imagine Congress enacting such a change.


March 26—The Medicare Payment Advisory Commission (MedPAC) announced a proposal to drop the Merit-based Incentive Payment System (MIPS) program in its annual report to Congress on needed changes to Medicare payment policies earlier this month. 

MedPAC expressed doubts that MIPS will achieve its designed goal of promoting high-value care. Instead, MedPAC’s recommendation is to take a different direction regarding physician payments by establishing a voluntary value program (VPP). 

With a VPP, clinicians would elect to be measured as part of a voluntary, self-organized group. Those clinicians would qualify for value-based payments based on their group’s performance on a set of population-based metrics, such as hospital readmissions and patient experience scores. 

François de Brantes, a leading expert on payment reform and alternative payment models, doesn’t see the proposal as much of a surprise since MedPAC was signaling the recommendation for months. “It isn’t very significant because any action on MACRA [the Medicare Access and CHIP Reauthorization Act], including a formal repeal of MIPS, would take congressional action, which is unlikely,” de Brantes said.

However, to some extent, the MedPAC proposal is already being acted upon, de Brantes said, noting that in the temporary budget deal that was passed in February, Congress gave the Centers for Medicare & Medicaid Services (CMS) quite a bit of latitude to manipulate MIPS rules as it sees fit. 

Although MedPAC’s announcement would seem to mesh with the Trump administration’s push to end MIPS quality reporting, Cybil Roehrenbeck, an attorney for Polsinelli and a former lobbyist for the American Medical Association, said a modification of reporting rules seems more likely. 

“There has been some discussion of claims-based reporting, but because of concerns that such data doesn’t adequately reflect quality or good patient care, we may see these proposals dialed back,” Roehrenbeck said. “More options and flexibility, rather than a full-on shift to claims-based reporting, seem more likely.” 

Roehrenbeck said there was no indication that MedPAC’s recommendations were on the table at a congressional oversight hearing on MACRA last week. “It’s hard to imagine a scenario in which Congress would repeal such a major piece of legislation that they enacted only three years ago,” Roehrenback said.

Groups Voice Opposition

Reaction to the MedPAC recommendation has been relatively uniform—essentially stating that it’s too late to turn back now but that adjustments could and should be made to make reporting fairer and perhaps less burdensome. 

Groups representing hospitals and medical practices have quickly voiced opposition to the MedPAC proposal while also requesting that data and experience in the field be used in making major changes to MIPS. For instance, both the American Hospital Association (AHA) and the Medical Group Management Association (MGMA) have expressed concern over the lack of details around the recommended voluntary value program. 

“MedPAC’s March Report is an indictment of MIPS as implemented,” Anders Gilberg, senior vice president of government affairs for MGMA, said in a statement. “However, its conceptual ‘VVP’ alternative lacks details. MGMA believes there are steps that can be taken now to reduce clinician burden. CMS can begin by shortening the 2018 MIPS data reporting period from one-year to 90 days in the same way the Agency did for Meaningful Use in 2014, 2015, and 2016.”

Nancy Foster, vice president for quality and patient safety policy with AHA, said in a blog post that MedPAC’s recommendation to eliminate MIPS is not only premature but also misguided. 

“Now is not the time to scrap the MIPS,” Foster said. “The MACRA passed with strong bipartisan support, and the VVP is not a compelling alternative. Moreover, hospitals and their clinician partners have made significant investments of time, effort, and other resources to prepare for the new program.”

The Future of MACRA

While MedPAC’s proposal may cast some doubt on the future of MIPS, de Brantes was quick to point out that since MIPS isn’t necessarily the key to MACRA, the administration should focus its energies, resources, and ideas on ensuring adequate opportunities to participate in advanced alternative payment models.  

“While MedPAC is proposing a new formula to replace MIPS, the alternative is no formula,” de Brantes said. “In other words, if the objective of MACRA is to encourage participation in advanced alternative payment models, that can be accomplished without complex MIPS reporting requirements or formulas.” 

Ultimately, Roehrenbeck expects that Health and Human Services Secretary Alex Azar will “continue to look for creative ways to reduce burden while amplifying results.” 

“MedPAC’s proposal to start a new voluntary program seems to be very far from the seismic change in care delivery that Secretary Azar has outlined,” Roehrenbeck added.

What’s more, Roehrenbeck said, MedPAC’s alternative VVP model seems to endorse a “one-size-fits-all” evaluation, “which is expressly what CMS and the Congress have tried to avoid in an effort to evaluate dissimilar providers equitably.”


Rod Moore is a medical writer and journalist based in Nashville, Tenn. Follow Rod on Twitter: @rodwrites

Publication Date: Tuesday, March 27, 2018