Primary care physicians can choose from two payment pathways in Medicare's new Quality Payment Program, but one of these tracks needs major reform if it is to meet CMS' goals of improving outcomes and reducing costs.
In its June report to Congress,(medpac.gov) the Medicare Payment Advisory Commission (MedPAC) made a detailed proposal to improve the Merit-based Incentive Payment System (MIPS) track by incorporating more patient outcomes while reducing the reporting burden on physicians. Physicians on the MIPS track as it stands now will be evaluated on quality, cost, practice improvement and use of electronic health records (EHRs).
The other track is the advanced alternative payment model (AAPM), through which physicians can qualify for higher incentive payments but also take on more risk. Physicians who successfully participate in an AAPM can earn a 5 percent incentive payment beginning in 2019 for delivering high-quality, coordinated and efficient care.
Some health policy analysts are skeptical that MIPS, as currently designed, will attract enough physicians to meet CMS' goals. MedPAC reported that the measurements used in MIPS will not distinguish between high- and low-performing practices, and that small differences in quality scores could produce a wide disparity in payment bonuses.
There are 275 quality measures in the MIPS program, and they primarily measure standards of care and processes -- such as whether a clinician ordered appropriate tests or followed clinical guidelines -- rather than outcomes. Physicians can choose which measures to report. The degree of difficulty varies widely among categories, and the program is unlikely to meet goals if many physicians select measures in which a large percentage of practices score highly.
"Many of these measures are poorly linked to outcomes of importance for beneficiaries and the program and, instead, reinforce the incentive in fee-for-service (FFS) Medicare to provide more services than are clinically necessary," the report stated.
In addition, individual physicians typically have so few patients that qualify for each measure that it may not be possible to distinguish real differences in performance from sample noise.
"MIPS as presently designed is unlikely to succeed in helping beneficiaries choose clinicians, helping clinicians change practice patterns to improve value, or helping the Medicare program reward clinicians based on value," the report stated.
Instead, MedPAC recommended using more population-based outcome measurements and relying on claims data and survey results instead of physician reporting.
Rather than evaluating physicians on office processes that they must report to CMS, the proposal suggests changing MIPS so it uses claims data to score performance in population health categories of preventable hospital and ER visits, mortality and readmission rates after hospital stays, healthy days at home, patient experience, rates of low-value care and resource use.
These data would provide insight into the ambulatory care setting and the entire delivery system without requiring physicians to report data at all.
"The benefits of using population-based measures are significant," the report stated. "This approach sends clinicians a signal that they should view the care they provide as part of a continuum that crosses sectors and incorporates the totality of patient care. This perspective helps to counter the silo-driven FFS system that encourages providers to focus only on the services they directly provide."
One drawback, the report notes, is that such a change would not provide information on individual practice performance.
If the proposals in the report are adopted, it also could prompt physicians who do not want to be measured against their local performance group to join a virtual group of practices, which, in turn, could prepare them to join an accountable care organization or another AAPM.
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