MedPAC takes aim at out­comes-based pay­ment pro­grams

Modern Healthcare - - NEWS - By Vir­gil Dick­son

The shift to value and out­comes-based pay­ment was thrown a curve­ball last week when an in­flu­en­tial con­gres­sional ad­vi­sory panel rec­om­mended cur­tail­ing some fed­eral pro­grams aimed at push­ing providers in ex­actly that di­rec­tion.

First, the Medi­care Pay­ment Ad­vi­sory Com­mis­sion rec­om­mended do­ing away with the Merit-based In­cen­tive Pay­ment Sys­tem, or MIPS. A day later, the com­mis­sion said it is work­ing on a pro­posal to have Congress elim­i­nate the In­pa­tient Qual­ity Re­port­ing Pro­gram and the Hos­pi­tal Ac­quired Con­di­tion Re­duc­tion Pro­gram. It will also ask that the Hos­pi­tal Read­mis­sions Re­duc­tion Pro­gram and the Hos­pi­tal Value-Based Pur­chas­ing Pro­gram be merged into one new pro­gram called the Hos­pi­tal Value In­cen­tive Pro­gram.

“There are cur­rently too many over­lap­ping pro­grams, which cre­ates un­needed com­plex­ity for Medi­care and for hospitals,” Le­dia Ta­bor, a pol­icy an­a­lyst at MedPAC, said Oct. 6 dur­ing a meet­ing. “For sim­plic­ity, hospitals should have their pay­ment ad­justed un­der one pro­gram as op­posed to sep­a­rate pro­grams.”

The new pro­gram would score hospitals based on read­mis­sions, mor­tal­ity and spend­ing rates as well as pa­tient ex­pe­ri­ence while in care. It would ac­count for the fact that some hospitals have more higher-need pa­tients than oth­ers by plac­ing hospitals in peer groups. All Medi­care hospitals would have 2% of re­im­burse­ment with­held. Hospitals that do bet­ter than oth­ers in their peer groups would re­ceive a bonus greater than what was with­held from them,

“There are cur­rently too many over­lap­ping pro­grams, which cre­ates un­needed com­plex­ity for Medi­care and for hospitals.” Le­dia Ta­bor Pol­icy an­a­lyst at MedPAC

and hospitals that per­form poorly will re­ceive back less than what was with­held from them.

Most no­tably, how­ever, the new model would not hold hospitals fi­nan­cially ac­count­able for in­fec­tions pa­tients de­velop while in their care. There’s been frus­tra­tion within the in­dus­try that hospitals are held ac­count­able for too many false pos­i­tives or neg­a­tives.

The CMS said the 769 hospitals with the high­est rates of hos­pi­tal-ac­quired con­di­tions had their Medi­care pay­ments cut in fis­cal 2017. The As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges es­ti­mated hospitals lost about $430 mil­lion in to­tal as a re­sult of the Medi­care pay­ment cuts, which was 18% more than the prior fis­cal year.

On the physi­cian side, com­mis­sion­ers con­tended that MIPS is too much of a bur­den and doesn’t drive im­prove­ments in care.

“Time is of the essence to de­velop an al­ter­na­tive for MIPS,” said David Glass, prin­ci­pal pol­icy an­a­lyst at MedPAC. It “will not achieve the goal of iden­ti­fy­ing and re­ward­ing high-value clin­i­cians.”

Un­der MIPS, physi­cian pay is based on suc­cess in four per­for­mance cat­e­gories: qual­ity, re­source use, clin­i­cal prac­tice im­prove­ment and “ad­vanc­ing care in­for­ma­tion” through use of health in­for­ma­tion tech­nol­ogy. The ad­vanc­ing care cri­te­ria is based on the gov­ern­ment’s mean­ing­ful use pro­gram, which is used to de­cide whether doc­tors should be re­warded for us­ing EHRs.

The CMS es­ti­mates that up to 418,000 physi­cians will be sub­mit­ting 2017 MIPS data.

But MIPS is se­verely flawed, ac­cord­ing to MedPAC. It is de­signed pri­mar­ily to mea­sure pro­cesses, such as whether a doc­tor or­dered ap­pro­pri­ate tests or fol­lowed gen­eral clin­i­cal guide­lines, rather than if pa­tient care was ul­ti­mately im­proved by that provider’s ac­tions.

“We re­ally have to get rid of MIPS,” said Dr. Rita Red­berg, a com­mis­sioner and car­di­ol­o­gist at the Univer­sity of Cal­i­for­nia at San Fran­cisco. “No one went into medicine to check all these boxes.”

An­other flaw, ac­cord­ing to MedPAC, is MIPS lets clin­i­cians choose the mea­sures un­der which they’re eval­u­ated. The worry is they’ll choose mea­sures on which ev­ery­one tends to per­form well.

The CMS es­ti­mated that providers will spend over $1 bil­lion to track and re­port un­der MIPS in the 2017 cal­en­dar year. That’s too much money com­pared to what could be saved or even the rewards that providers could get, the panel said. MACRA only al­lows for up to $500 mil­lion each year in pos­i­tive pay ad­just­ments for per­form­ing well un­der the sys­tem.

In place of MIPS, the panel sug­gested that all Medi­care physi­cians not in an al­ter­na­tive-pay­ment model, or APM, would have 2% of their pay­ments with­held. The CMS es­ti­mated that 180,000 to 245,000 clin­i­cians will be in an APM by the end of 2018.

While not a pol­icy-cre­at­ing body, MedPAC is an in­flu­en­tial voice for both Congress and the CMS. Most re­cently, its site-neu­tral pol­icy for hos­pi­tal off-cam­pus fa­cil­i­ties was fi­nal­ized in a rule­mak­ing last year.

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