MACRA, Physician Reimbursement, and Moving beyond MIPS

Dr. Gail R. Wilensky, Ph.D has just wrote a thought provoking perspective in the New England Journal of Medicine. ("Will MACRA Improve Physician Reimbursement?" April 5, 2018)

Tracking the journey from Resource based relative value scale (RBRVS) and Sustainable growth rate formula (SGR) which was not really a value based system, to current MIPS portion of MACRA (Medicare Access and CHIP Reauthorization Act); it becomes clearly evident that it is still work in progress. 

MedPAC March 2018 Report to Congress - Monkey Wrench

While agreeing with the initial goal of MIPS, MedPAC has thrown a monkey wrench, claiming that MIPS is a burden along with the claim that it's goal will not be accomplished.

MedPAC shares Congress’ goal, expressed in MIPS, of having a value component for clinician services in
traditional Medicare that promotes high-quality care. However, the Commission believes that MIPS will not
fulfill this goal and therefore should be eliminated.
— MedPAC March 2018 Report

They are making two recommendations:

  1. Eliminate MIPS as it is today.
  2. Establish a new 'Voluntary' value program in fee-for-service.

As Dr. Wilensky points out, 'Under the MedPAC proposal, physicians would have 2% of their fee-for-service payments withheld. To get the withheld money back, physicians would have to join an A-APM or be part of a (real or virtual) group that is evaluated on population-level performance measures such as mortality and readmission rates, potentially preventable admissions, and patient experience. MedPAC also proposes that the measures be based on claims, which would mean that the burden would be on CMS rather than clinicians to provide the relevant data. Clinicians who do not participate would lose the 2% that was withheld.'

Even if we agree with MedPAC's assessment that MIPS has flaws, I'm not sure if anyone has the answer. MedPAC has an alternative proposal, but dumping MIPS altogether is probably not wise, until CMS tests and tries the MedPAC proposal. Dr. Wilensky proposes that CMS should test it under its Innovation Center (CMMI).

In either case, we are certainly making progress. This is such a huge issue that we must test and try various models. There is no silver bullet. While Practicing Physicians will encounter a bumpy road, we must all pitch in to make our views known and heard.