Sunday, November 8, 2015

Much Interest in CMS Reform of Physician Incentive Metrics ("MIPS" regulations)

Last spring, Congress repealed the longstanding SGR policy for the CMS Part B physician fee schedule.  The legislation also set in motion what could be a big overhaul of the physician performance metrics like "PQRS."   Nearly 200 comments on the topic are already on the website.  Meanwhile, until Tuesday, November 17, CMS is requesting additional deep dive comments through a special MIPS "request for information" process.

What Happened in Spring 2015?

Congress repealed the longstanding SGR (sustainable growth rate) principle that applied to the Medicare physician fee schedule.  The legislation was called MACRA - the Medicare Access and CHIP Reauthorization Act of 2015.  (See here or here.)

Besides repealing SGR, another section of the law requires Medicare to consolidate and redesign its complex physician performance metrics, such as the PQRS system and the EHR incentive system.  The new system, "to be determined" in detail, will be called MIPS, the Merit Based Incentive Payment System.  However, to my eye, CMS could fulfill MIPS by just pasting together today's cumbersome and jerry-rigged sandbox of metrics, or, CMS could take the opportunity to build a new and better system.

Summer Rulemaking Triggered 193 Comments on MIPS

The dockets folder for the summer physician fee schedule rulemaking has 2,288 total public comments available for viewing (if you search here).

If you restrict your search to public documents commenting on the future MIPS system, you get 193 hits (refine your search as here.)

I downloaded almost all of the 193 files, resulting in a 60 MB folder.  The MIPS commenters are diverse, from Kaiser to Pfizer, from the American Association of Medical Colleges to the Healthcare Information and Management System Soceity (HIMMS) to the Cancer Leadership Council.

So you don't have to point and click at 190 tabs on - which is about 190 x 10 seconds or 1900 seconds or a half hour -  I've put the comment documents in one consolidated 60 mb zip file, in the cloud here. (Click on the little "down" arrow in the top border of the webpage).

CMS has a MIPS webpage, here.

The CMS "RFI" for MIPS is Open Until November 17, 2015

CMS issued a separate and quite detailed (over 200 questions) "Request for Information" about MIPS.   The request for information is online here (80 Fed Reg 59102ff, October 1, 2015).  CMS extended the comment period from the original closing date, November 2, to the new closing date of November 17, 2015 (extension PDF here, submit comments here).

MEDPAC and MIPS: October 2015

MEDPAC had an extended discussion about MIPRA in its October 8-9 session (agenda here).  The online public transcript of the MEDPAC-MIPS discussion is here at page 90 ff.


Health Affairs published a blog on the MIPS opportunity, authored by CMS, here and AMA has weighed in, here, and there's been an NEJM opinion piece, here.

The most pungent analysis may be that which the Medical Association of the State of Alabama submitted in an early MIPS RFI comment, dated October 30, 2015, here.

CMS’s duties are often executed in the least helpful manner possible for physicians, rarely improving delivery of care and in most cases further burdening physicians with pointless administrative hoops through which we must jump.  Most physicians find “meaningful use” to be meaningless and PQRS to be overly complicated and cumbersome. 
In situations like the Physician Open Payments Database, CMS’s “data dump” of raw payment information and lack of context provided gives the public no clear way to intelligently interpret the data, likely causing some patients reviewing it to reach inaccurate conclusions about their physicians and unnecessarily casting a black eye on the noble calling of medicine. .... It seems CMS’s intent is to complicate delivery of medical care across the board. None of this should be the case – CMS should strive to work with, not against, physicians.  ...Just because CMS and certain insurers are unable to attract physicians to see more of the patients under their jurisdiction because they offer poor reimbursement and place tremendous administrative burdens on providers does not mean CMS has the liberty to dictate that we must bend to its will...This heavy-handed approach has exacerbated early retirement from the medical field and contributed significantly to physician shortages across the country, especially in poor and mostly rural states like Alabama....While Alabama’s medical community is sincerely interested in helping CMS find ways to responsibly expand access to care, manage vulnerable populations, maintain quality and safety and better coordinate care, dictation to us of how we run and hopefully grow our practices is not the answer. We implore you to abandon this idea and the agency’s current direction for [a new direction] that “meaningfully” – to borrow a phrase CMS is quite fond of – engages physicians and incentivizes them to participate in the programs under the agency’s jurisdiction.
An individual, D.B. of Arkansas, commented similarly:

However, as a regulatory body and society in general, we need to understand that we are punishing medical providers with overreaching programs and regulations that providers are finding it very difficult to keep up with. These well-meaning programs come at a time when we are already experiencing a physician shortage and the projections are for a
looming shortage that will greatly affect access to medical providers within the next ten years. I would suggest that as we modify the existing programs we involve more physicians and seasoned medical administrators so that with the additional input, we improvise programs designed to reward physicians for quality care without completely frustrating them in our exuberance for better quality...Patient Centered Medical

Home, MU, PQRS and basically any and all programs that have been developed in theory to improve our care of patients. While the goals were admirable we are finding that our physicians cannot see nearly as many patients due to the inefficiencies involved with complying with these programs..
To find parallels in a different forum, see the September 8, 2015, comment on current physician metrics by the American Board of Internal Medicine:

With respect to specific proposed activities and measures, we cannot recommend strongly enough that CMS take a broad view of eligible practice improvement activities, and we believe this is what Congress intended to signal with its list of “must include” categories. There are as many opportunities to improve patient care and workflow in practice as there are steps in clinical and organizational processes, and dozens of institutions and practices and thousands of physicians who work in them already are working to improve quality based on local needs and priorities. 
CMS should not risk stalling those efforts in the course of stimulating more. As we have seen with other well-intentioned federal physician quality initiatives – PQRS and Meaningful Use – a narrowed field of prescribed choices can cement the current state of the art into a fixed status quo, distract clinicians from what might be higher-yield opportunities in order to claim the incentive or avoid the penalty, blunt the meaning of the effort and breed anger and cynicism. Prescription is not the right tool to foster an ecosystem conducive to real physician engagement in practice improvement.