The Folly of MIPS

You’re surely aware that the Quality Payment Program (QPP) is the centerpiece of MACRA, the Medicare Access and CHIP Reauthorization Act. MACRA is replacing the much-maligned Sustainable Growth Rate (SGR) process for updating the Medicare Physician Fee Schedule. So far, so good, right?

The QPP calls for physcians in Medicare Part B to choose between the Merit-based Incentive Payment System (MIPS), or in an advanced alternate payment model (APM). The biggest concern I see is the potential to game the system by fudging reporting or excluding certain physicians and patients that don’t fit the criteria for incentive payments, a concern that many healthcare leaders share. A study published online in January in the Annals of Internal Medicine on pay-for-performance programs concluded that P4P “may be associated with improved processes of care in ambulatory settings, but consistently positive associations with improved health outcomes have not been demonstrated in any setting.”

To reach this conclusion, researchers performed a meta-analysis of 69 studies published between 2007 and 2016. Most of the improvements through incentives were found in the United Kingdom, which features a richer incentive package than in the United States.

Cedars-Sinai Medical Center internist Teryl K. Nuckols, MD, in an accompany editorial, notes the potential to game the system through the selection of healthier patients, excluding doctors with low scores or falsifying documentation to bolster improvement measures.

“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,” he writes in the editorial.

I also see a disconnect between when the reporting occurs and when the bonuses are given or penalties levied. There is a 2-year gap, which does nothing to modify behavior on a grand scale. What if hospitals conducted morbidity and mortality conferences 2 years after an incident, instead of weekly, biweekly or monthly as is the custom for most health systems? Changes may help the 100th patient or the 1,000th patient, but it would do nothing for those in between who may be subjected to the same error or faulty workflow.

Providers and healthcare associations also are concerned about what they perceive as onerous reporting requirements under MIPS as well as Stage 3 Meaningful Use. Sixteen healthcare organizations joined in a March letter sent to Secretary Tom Price, MD, the new leader of the Department of Health and Human Services, asking for a delay in implementation of both mandates. Because so few EHRs have been certified, it seeks an indefinite delay in Stage 3 Meaningful Use.

Lack of certification also bodes ill for MIPS, because providers still are not comfortable with the technology, the letter writers maintain.

And then there’s the question of when the MIPS standard finally will be released. Although the program technically has started, CMS still has not offered guidance on how providers comply during the calendar year, despite assurances guidance would be available in December. The Medical Group Management Association (MGMA) submitted a letter to new CMS Administrator Seema Verma in mid-March requesting the immediate release of the standards. The MGMA represents 33,000 administrators and executives in 18,000 healthcare organizations.

“Transitioning to MIPS is a challenge involving upgrades to electronic health record software, reengineering clinical workflows to meet data capture and reporting requirements, contracting with data registries, and training clinical and administrative staff,” the letter states. “Without basic information about eligibility, physicians and medical groups are significantly disadvantaged from positioning themselves for success in the program.”

In theory, MIPS may bring more accountability to physicians and group practices for the care they provide. But the current design, ability to game the system, delay between reporting and payment and continuing technical challenges render MIPS meaningless in its current form.