Physician Payment and Reimbursement

Medicare Quality Pay Leads Practice Regulatory Burden

October 3, 2018 8:54 am

Physician practice leaders say the lack of ROI has led some to weigh whether to continue to participate in MIPS or just accept Medicare payment penalties.

Oct. 2—Although insurance prior authorization and electronic health record (EHR) interoperability have garnered extensive attention as challenges for medical practices, a new survey fingers Medicare quality payment programs as the biggest hindrance.

The Medicare Quality Payment Program (QPP), specifically the two arms of Medicare physician compensation—which went into effect nearly two years ago—was named as very or extremely burdensome by 88 percent of practices in a new poll by the Medical Group Management Association (MGMA).

The next highest practice burdens stemmed from prior authorization (cited by 82 percent as very or extremely burdensome) and EHR interoperability challenges (80 percent), according to the 426 practice executives polled.

“It’s not often you get that kind of consensus,” said Anders Gilberg, senior vice president for government affairs for MGMA. ”But in no way did it mean folks are anti-quality or anti-value-based care.”

Instead, the results underscored the frustration of practices with the current value-based payment (VBP) options, he said in an Oct. 2 address at the MGMA Annual Meeting.

The vast majority of MGMA member practices (79 percent of survey respondents) participate in the Merit-based Incentive Payment System (MIPS), one of two Medicare payment arms for physicians. Fewer practices are in advanced alternative payment models (APMs), which comprise the second arm and require much less quality reporting. Both were created through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

“You’re getting pretty good at [quality reporting], but you’re also getting stuck in a rut,” Gilberg said about practice frustrations.

That dim view has developed as practices have come to see MIPS as a quality-reporting initiative, rather than a quality-improvement initiative, as well as a lack of APMs that are good fits for practices.

For instance, 55 percent of practices were dissatisfied with the “availability of applicable measures” under the Medicare payment program.

On a related note, the MGMA survey found that 76 percent did not see improvement in the quality of care their patients receive resulting from the high-profile move of Medicare and Medicaid toward VBP, while only 15 percent said the push has improved their patients’ care.

But the VBP shift in has increased the regulatory burden for practices, said 90 percent of respondents.

The leading complaint about Medicare’s new physician payment program related to “reporting requirements and methods,” with which 67 percent of practices said they were dissatisfied or very dissatisfied.

The Trump administration has said it is prioritizing provider paperwork reductions and recently proposed $1.1 billion annual reductions in regulatory requirements.

Not Much of an ROI

Practices also were concerned about the cost of complying with Medicare’s VBP initiatives. For instance, one practice that garnered MIPS bonus payments received an ROI of about 60 percent from the program, said Jennifer McLaughlin, JD, senior associate director of government affairs with MGMA.

Attendees who spoke at the meeting said practices that have seen a lack of ROI are weighing whether to continue to participate in MIPS or just accept penalties.

Gilberg said that despite practices’ frustration with the QPP, it is not going away.

“Deficits are increasing, more scrutiny is on the Medicare program to deliver a high-quality, low-cost, efficient opportunity for all patients and beneficiaries, and that’s exactly what we’re trying to do here,” Gilberg said.

He said MGMA is pushing for tweaks that would base Medicare payments on more clinically relevant approaches.

McLaughlin said it has been a challenge to fit unique group practices into the “one-size-fits-all-box of MIPS,” which requires reporting on measures that may have little relevance to many practices. MGMA is pushing for a change that was included in the 2019 physician payment proposed rule and would allow specialists to report a MIPS quality measure related to their specialty using claims data.

The Medicare Payment Advisory Commission (MedPAC) recommended in its latest report that Congress scrap and replace MIPS. But MGMA does not support the proposed replacement, although it maintains that MIPS quality measures are frequently irrelevant to specialty practices.

Congress “has had us up on several occasions to talk about how they can improve it, but they still see [MACRA] as the framework for right now,” McLaughlin said.

Gilberg said MACRA was designed to push providers into APMs by making MIPS participation “painful.”

The “roadblock” has been the lack of acceptance by the U.S. Department of Health and Human Services (HHS) of any of the more than 20 physician-focused APMs that have been recommended by the Physician-Focused Payment Model Technical Advisory Committee (PTAC), he said.

Although only 11 percent of practices said any of the APMs that HHS has approved were clinically relevant and aligned with practices’ quality goals, 44 percent would be interested in such models if they were created.

“It has been three years; we need to get going,” Gilberg said, referring to the period since MACRA’s enactment.

Issues with Prior Authorization

Outside of government payers, the longstanding and still significant challenge that practices face from insurers remains the use of prior authorization, said Robert Tennant, a policy director at MGMA.

The challenge has resulted in impacts on patient care, such as when the process limits the timeliness of medications or requires patients to retry medical therapies when they switch health plans.

Another challenge, according to practices, is that different health plans require a wide range of approaches to completing prior authorization, which adds to paperwork burdens.

Prior efforts to create a standardized electronic prior-authorization process stumbled over the inability to share supporting clinical information. Practices have been waiting 20 years for an electronic-attachment standard for prior authorizations, Tennant said.

In the meantime, practices polled on an ongoing basis by MGMA perceive that prior-authorization requirements have become more onerous, Tennant said.

In response, MGMA joined a coalition of provider organizations to create “limiting principles” for the use of prior authorization in some instances, such as emergency surgeries. More than 100 provider organizations ended up endorsing the principles, which led health plan advocates to meet to discuss the issue last year. That meeting produced a recognition by health plans that they need to address some issues related to prior authorization, Tennant said.

“It didn’t get everything we wanted, but at least it was recognition from the health plans that they were willing to at least address some of the issues,” Tennant said.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare 


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