The findings may provide a preview of which types of practices will face the biggest quality reporting compliance hurdles to avoid MACRA’s steep penalties.

Dec. 4—Large shares of practices opted for Medicare pay cuts rather than complying with complex and costly reporting requirements in a recent physician payment program.

In 2013, the Centers for Medicare & Medicaid Services (CMS) rolled out its Physician Value-Based Payment Modifier Program (VM) to test whether a data-driven system of financial incentives could bend Medicare quality and cost curves.

A study published Dec. 4 examined VM data from 2013 – affecting physician fee-for-service Medicare payments in 2015 for groups of 100 clinicians or more – suggested the federal government’s incentives to buy electronic health records (EHRs) might be paying off.

But the VM program is nearly a dead letter since 2018 is its last payment adjustment year, based on 2016 data.

CMS is replacing VM with the Quality Payment Program under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and its two payment divisions: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs).

Researchers and policymakers expected some of the VM program’s first-year data to provide lessons that can be applied by providers and MIPS policymakers.

MIPS wraps up its initial quality reporting year this month. Non-exempt clinicians who fail to report face a 4 percent cut in their total 2019 Medicare payments.

Crunching the VM numbers from 2013, researchers found that higher-than-average EHR proficiency by a group’s clinicians was “strongly associated” with higher performance on both quality and cost improvement measures.

But their most important finding, according to Karen Joynt Maddox, MD, one of the study’s authors, was that 29.3 percent of medical groups of 100 or more clinicians – 263 of the 899 groups that were eligible to participate in the VM program in 2013 – failed to register and successfully report data to CMS. Their 2015 Medicare payments were cut 1 percent.

“These are the biggest of the biggest, arguably the most well-resourced practices,” said Maddox, an assistant professor of medicine at the Washington University School of Medicine in St. Louis. “That was a calculated decision. Why would practices voluntary lose 1 percent of their revenue?”

Maddox has a hunch.

“The burden is significant,” Maddox said, and the technology available to physician practices has yet to lift that load.  

“We are a long way from the kinds of electronic, record-keeping infrastructure that we need,” Maddox said. “That’s going to take some [more] investment and some time.”  

Maddox’s findings were published in the December issue of Health Affairs.

Digital Divides 

The researchers point to evidence in the VM data of multiple digital divides.

Groups that failed to report mandated data in 2013 served higher proportions of Medicare/Medicaid dual eligible, black and Hispanic patient populations, and tended to be smaller and more rural than those that met their VM data reporting requirements. 

The authors warned that “the benefits of value-based payment might not accrue equally to disadvantaged populations.”

They recommended that policy makers provide adequate technical support to groups in need to ward against inadvertently widening existing disparities with MIPS.

The authors also cautioned that previous studies examining the relationship between EHR use and quality in ambulatory care yielded “mixed results.”

Still, they concluded practices adept in the use of health information technology “may stand to do particularly well” under the coming MIPS program and that “practices without such capabilities could be particularly vulnerable to penalties.”

Robert Tennant, health information technology policy director for the Medical Group Management Association, concurred that, for some groups, reporting in 2013 wasn’t worth the effort.

But Tennant challenged the assumption that opting out had any correlation with the quality of care received by patients of those non-participating groups.

“They’re using their data to drive behavior within their practice” in a timely manner while “reporting to CMS is really not actionable,” Tennant said. “I wouldn’t want those groups to be characterized as low-quality groups because there is no correlation between quality and quality reporting.”

The American Medical Association (AMA) has been critical of MIPS throughout the rule-making process. In May, the AMA with consultant KPMG released results of a survey of 1,000 physicians in which 90 percent found MIPS to either be “very burdensome” (53 percent) or “slightly burdensome” (37 percent). 

By late August, however, James Madara, MD, president of AMA, in a letter to CMS Administrator Seema Verma, thanked CMS for proposing a menu of compliance paths for MIPS while expanding its exemption threshold. 

The latter change raised the physician exemption threshold from $30,000 in Medicare Part B charges and 100 Part B patients to $90,000 in charges and 200 patients. Both changes stayed in the final rule CMS released in November.

Due to this and other exclusions, just 37 percent of individual eligible clinicians and groups will be subject to MIPS reporting requirements in 2018, according to the CMS. 

Michael Munger, MD, president of the American Academy of Family Physicians, said many of the medical specialty society’s 129,000 members have submitted quality data for years to CMS. Most are ready for MIPS, he said, but more than a quarter of them will be excluded from participation by the higher threshold. Not a good thing.

“To participate means a chance to have a positive payment adjustment,” he said. “In our comment on the proposed rule, we really thought practices should be given the opportunity to participate, and not be automatically excluded.”

The AMA also urged CMS not to include cost scoring in payment calculations for several more years.  But, after excluding cost scoring from the MIPS proposed rule, a 10 percent weight for a CMS-calculated cost score was added back in the MIPS final rule for the 2018 reporting period.

MedPAC Opposition 

At its monthly meeting Oct. 5, MedPAC tore into MIPS. A MedPAC slide presentation referred to MIPS as “extremely complex,” while placing a “significant burden” on physicians, citing CMS’s own estimate of $1 billion in reporting costs for 2017 alone. 

Further, it said, MIPS process measures are “not associated with high-value care.” MedPAC prefers measuring patient outcomes directly.

“MIPS will not achieve [its] goal of identifying and rewarding high-value clinicians,” the MedPAC presentation said. It called for Congress to “Eliminate MIPS and create a new voluntary value program” to replace it.

With all its exclusions and flexibility, according to MedPAC, MIPS could exempt an estimated 800,000 clinicians. And that’s a dilemma, according to the researcher Maddox.

“If that’s a permanent thing, we’ll have a problem changing the quality of outpatient care in this country,” Maddox said, and yet, “the burden thing is real.”

“The question is finding the sweet spot between reducing burden and doing what’s best for patients,” she said.   

Joseph Conn is a freelance writer based in Chicago. Follow Joe on Twitter at @JConnHIT.

Publication Date: Monday, December 04, 2017