October 13, 2017

MedPAC Considers MIPS Repeal, Telehealth Reports

The Medicare Payment Advisory Commission (MedPAC) considered options to repeal and replace the Merit-based Incentive Payment System (MIPS) and deliberated on mandatory telehealth reports at its Oct. 5 meeting. Summaries below cover these two highlighted topics.

Merit-based Incentive Payment System

MedPAC convened last week with recommendations to potentially repeal MIPS and replace it with an alternative, population-based Voluntary Value Program (VVP). Although the MedPAC commissioners are very close to recommending MIPS’ repeal in favor of population-based measures, questions remain about the alternative policy and the need for improvements.

MedPAC is planning a reassessment at its December 2017 meeting and has asked for further information to repeal MIPS and work through two options for those who cannot access Advanced Alternative Payment Models (A-APMs). They are as follow:

  1. VVP — A population-based policy alternative with adjustments and improvements, such as adding criteria for measure selection. However, the commissioners remained concerned with the level of specificity that should be included.
  2. Substantially change the rules and regulations applied to A-APMs. This version would smooth the pathway to A-APMs (i.e., make them more accessible giving most physicians an option they can pursue/achieve).  

MedPAC raised major concerns with MIPS. A majority of advisory group members believe MIPS is unsustainable, burdensome, complex, costly, lacks information on physician compare challenges (i.e., risk adjustments per individual physician) and will not achieve its intended goal of producing high-level care. Although MedPAC is closing in on the repeal of MIPS, numerous questions remain on the road to replacement. Kate Bloniarz and David Glass, both MedPAC staff members, presented on a policy alternative to replace MIPS with VVP population-based measures as follows:

  • All clinicians would have a portion of fee schedule payments withheld (e.g., 2 percent)
  • Clinicians could:
    • Elect to be measured with a sufficiently large entity of clinicians (and be eligible for a value payment)
    • Elect to join an A-APM (and receive withhold back); or
    • Make no election (and lose withhold)
  • Entities would be collectively measured on population-based measures assessing clinical quality, patient experience and value (similar to A-APMs)

While generally favoring VVP population-based measures, MedPAC commissioners questioned whether this alternative policy was fully ready and had numerous considerations and questions on improvements as described below.

  • Concerned that a 2 percent withhold may not be a sufficient incentive. Consideration to increase penalty.
  • Concerned with the ability to meet the population-based measures (e.g., for small and rural providers)
  • Recommended the addition of risk adjustments — Clinician variables/high costs/comorbidities/resource utilization
    • Draw and learn from Accountable Care Organizations (ACOs) and apply to either reformed MIPS or alternative policy — Importance of risk adjustments
  • Regarding the 800,000 exemptions — What are the actual physician numbers versus a total that is artificial and inflated with non-physicians?
  • The Office of the Inspector General (OIG) report indicates that it will take more than three years to transition — Consideration needed on the replacement option and issues with readiness implementation
  • Move away from process measures
  • Virtual Groups/specialists — Are we creating the same behaviors that arose from the failed Sustainable Growth Rate (SGR) policy?
  • How is it different from APMs?
  • With voluntary population based measures — Concerned about which physicians might get left behind; recommendation to build incentives to get into groups; alignment with strong clinicians
  • Recommendation — Primary Care (PC) must be part of an A-APM and have the voluntary model available for the specialists
    • Commissioners perception/misperception - MIPS is not a problem for PC but it’s the “five percenters” (specialties including radiology) that are challenged with meeting MIPS. Asked to think about the heterogeneity.
  • Determine which elements that should be mandatory versus voluntary (e.g., Meaningful Use should be mandatory)
  • Analysis needed in the APMs — Breakdown of PC versus specialists and the drivers of issues
  • Tie penalties and rewards — Part B to Part A
  • Are A-APMs available to most physicians?

Summary — Next Steps

The Commission’s plan is to return to this issue at the December meeting to review draft recommendations for MIPS repeal and the policy alternatives (i.e., VVP population-based policy with improvements and substantially changed A-APMs to include make more accessible). MedPAC will vote on recommendations at the January meeting for inclusion in its March 2018 Report to Congress.

Mandatory Telehealth Reports

The October meeting also featured MedPAC unveiling the broad conclusions of the second in a series of three statutorily mandated reports on telehealth. The 21st Century Cures Act, a landmark bill that increased medical research funding and streamlined the Food and Drug Administration review and approval process for medical devices and pharmaceuticals, included provisions requiring MedPAC to complete three telehealth reports no later than March 15, 2018.

Last month, MedPAC commissioners discussed the results from the first study pertaining to payment for telehealth services under the Medicare Parts A and B fee-for-service system. The October report focused on telehealth services within private insurance plans. The November meeting, in turn, will discuss ways in which telehealth services covered under private insurance plans might be incorporated into the Medicare fee-for-service programs, as well as outline specific policy changes that Congress or the Centers for Medicare & Medicaid Services can take to implement the recommendations.

The October telehealth report cited conclusions made after MedPAC completed 16 site visits, convened 12 focus groups in Indiana, Virginia and Washington State and conducted 11 interviews with home health agencies in Maine, New Jersey and Pennsylvania.

There was solid disagreement among the commissioners about the importance and usefulness of telehealth both in commercial insurance and fee-for-service Medicare. The commissioners fell into two camps regarding telehealth coverage. One group of commissioners, including Rita Redberg, MD, and Kathy Buto, concluded that the site visits, focus groups, and interviews do not provide adequate evidence about the underlying usefulness of telehealth in both commercial insurance and fee-for-service Medicare. Telehealth’s inability to produce substantial quality improvement, cost reduction and lower utilization levels makes any substantial policy changes to facilitate its spread less important.

A separate collection of commissioners, including Warner Thomas, Amy Bricker, Paul Ginsberg and Craig Samitt, were not so quick to completely discount the potential benefits of telehealth. Instead of considering the data results in terms of wholescale policy changes, this select group favored Medicare piloting expanded telemedicine coverage in risk-based ACOs or within discrete medical services, such as in neurology for telestroke and psychiatry for mental health consults.

This collection of commissioners also pointed to anecdotal evidence from the private sector which demonstrates that expanded access to telehealth prompts beneficiaries to cut down on in-person health care services, thus translating into health care savings. As a result, these commissioners argue telehealth services should not be viewed simply as an added bonus for beneficiaries but rather a bona fide approach to conserving scare medical resources.

The ACR will continue to monitor future MedPAC meetings for additional information on both MIPS and telehealth recommendations.