It’s time for a new acronym. You might not have heard of an organization called MedPAC, the Medicare Payment Advisory Commission. MedPAC has a lot of influence and no power. Or maybe it’s the other way around. It is an independent US federal body established by the Balanced Budget Act of 1997. This is ironic because the Balanced Budget Act created the Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula that was going to necessitate a 25% reduction in physician payment in 2015. The SGR was the looming catastrophe that caused Congress to enact the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA. Contained within MACRA is the Merit Based Incentive Payment System (MIPS) to which most physicians who take Medicare became subject in 2016. Are you still with me? MIPS is the latest and biggest step by the Centers for Medicare and Medicaid Services (CMS) in moving physician payment away from volume based payment to . . .something else, hopefully better but that’s not certain.
MedPAC is a 17 member commission appointed by the Comptroller General of the United States to serve a 3 year, possibly renewable, term. It’s a part time job but an important one- to advise Congress on issues affecting the Medicare program. Their mandate includes advising the US Congress on payments to the practitioners (and the private health plans) participating in Medicare. However, they can evaluate just about any issue that affects Medicare. MedPAC produces two major reports to Congress each year, one of which will be submitted this coming March.
Last Thursday (Jan. 11) MedPAC recommend replacing the MIPS with a voluntary program that would live back in the good old, fee-for-service Medicare world that would let doctors form groups that could earn bonuses if they perform well on population-based measures. Apparently not all 17 of the commissioners supported this recommendation.
I think there’s a little irony in the fact that the Balanced Budget Act that created the MedPAC also created the SGR that created the crisis that necessitated MIPS which the MedPAC has now recommended be replaced with . . . .uh . . .doctors volunteering to do a really good job.
Every Criticism MedPAC Had About the Quality Aspects of MIPS is True
I agree with every word of criticism MedPAC had for the “quality” aspect of MIPS. I am neck deep in my own 2017 MIPS quality measure submission, and am reviewing the quality measure programming for next year in my role as the Executive Director of the U.S. Wound Registry. I’m reviewing the quality analytics of several hundred of my wound care colleagues who are using the USWR to effect bonus money under MIPS. I can tell you every darn thing that is wrong about the way this system is designed-assuming you actually wanted to measure quality instead of proving that people who got through medical school are good at taking tests.
For starters, the current trend in quality measurement is toward “population” measures. Doctors do not treat populations. They treat individual people. Next, there are specific activities that define whether I did my specific job with any given patient. As a wound care practitioner, these activities and interventions are completely different than the activities that define whether the cardiologist downstairs did his job, or the hand surgeon next door did his. The idea that all three of us can measure a patient’s BMI, inform them that they are obese, recommend that they stop smoking, and get the nurses to record the details of their medications – and then say that’s a fair assessment of the quality of our completely different specialty practices is ridiculous in the extreme. I don’t know what kind of expert started this canard but we all know that it’s ridiculous. We do not need measures that are LESS specific to what each of us do. We need measures that are more specific. Assuming, of course, that you actually want to measure what we do, or how our patients do.
Measuring Quality in Wound Care
The US Wound Registry was able to keep 10 of the 21 wound and hyperbaric quality measures we once had approved by CMS as part of the USWR. We were also able to add a new quality measure in 2018, Patient Reported Nutritional Screening. I’d like to replay (more or less faithfully) a conversation I had with the group at CMS that decides which measures the Qualified Clinical Data Registries get to keep.
First, you need to know the Kafkaesque logic behind whether a measure is rejected. Remember that doctors are monetarily incentivized to report the measures on which they have the highest score. That’s how you get bonus money. However, CMS then evaluates the passing rate of the QCDR measure and if the scores on a measure are too high, CMS rejects the measure using the logic that it isn’t needed anymore because there is no “gap in practice.” The problem is that lots of people fail the measure – specifically, the ones who didn’t report it- because that’s the way the program rules are designed.
Last year the handful of wonderful wound care practitioners who reported the measures for arterial screening, venous compression and diabetic foot ulcer off-loading had very high scores on them. As a result, CMS said they were going to reject all 3 of those measures this year. I actually started crying on the phone. Yes, it was extremely embarrassing. However, in my defense CMS scheduled the conference call to discuss the measures in the middle of my Monday clinic (I did not get to pick a time that worked for me) and I had very sick patients and the place was chaos and I was standing in my office with CMS people telling me that we did not need off-loading of DFUs or compression of VLUs or arterial screening – and suddenly I felt like my life had been wasted- and I lost it.
I told them that I could show them the low scores of all the people who didn’t report the measure because their scores were low. Their answer was that I ought to MAKE them report low scores. I said, “WAIT- you hold the Mad Hatter’s tea party and invite me to it. You make the rules. I am just Alice. I am not the Queen of Hearts. I can’t make anyone do anything. They get bonus money for reporting high scores. Until the day dawns that we report a suite of measures that are actually relevant to our practices, we pick the measures we score the highest on. It’s crazy but that’s the way it works. You guys make the rules. Do you actually not understand the way this works?” Yes, I said that, almost word for word.
MedPAC is right about some things. This is ridiculous system that does not measure quality. Most of the work on the MIPS measures is done by nurses. It measures whether you have enough staff and whether your office has repeatable processes, but not whether you provide quality care.
Are you wondering what happened?
CMS let me keep those measures. I think they were afraid I was unhinged. And this is where it gets even nuttier. Thanks to the fact that CMS let physicians “pick their pace” in 2017, the USWR was able to report a broader range of scores without jeopardizing anyone’s bonus money. In other words, a lot of practitioners just wanted to avoid a penalty but weren’t trying to get a bonus, so they only needed to report one measure and they didn’t care about their score. That meant the USWR could report LOW scores on lots of measures. And that actually means that the practitioners who want to go after bonus money are more likely to get it. I know this is crazy but here’s why:
Bonus money is tied to where you are in relation to the class! So, you need some of your colleagues to do badly because that increases the chances that you will be in one of the top deciles! Ironically, allowing physicians to “pick their pace” again in 2018 means that the practitioners who do go after bonus money are actually more likely to get it- but only if they are using “non-MIPS” measures inside a QCDR like the USWR.
The problem with the standard MIPS measures is that no one reports them unless they have a practically perfect score. That means if you miss, for example, BMI screening on one patient in your practice, you could drop 2 deciles. However, if you report the arterial screening measure in the USWR QCDR, you could do a merely decent job and end up at the head of the class.
We Can’t Have it Both Ways
It IS the Mad Hatter’s tea party. The problem is that we can’t have it both ways. As practitioners, we can’t say we want to get paid for quality, and then just have a system you can totally game. That’s what this is. We complain because it’s stupid and doesn’t measure quality, but if anyone actually came up with a plan to measure quality… there would be a lot of screaming, because no one really wants to be held to a standard.
I will give you one specific example, and that is the USWR venous compression measure. That measure requires that a patient with an active venous ulcer is put in “adequate” compression. We define “adequate” as a system that has published evidence to demonstrate that it can heal venous ulcers. But every day, clinicians call Customer Care and complain about the fact that when they use one layer of tubular bandage they don’t pass the compression measure, or that anti-embolism stockings or ACE bandages or don’t pass the measure. WHY IS THIS SO HARD? There are so many great products on the market that work to heal venous ulcers. CAN YOU NOT JUST PICK ONE OF THOSE?
And for the record, it would be very helpful if the companies that make those excellent compression products would fund the analysis we need to do to demonstrate (yet again) that providers who USE adequate products are more likely to heal venous ulcers than those who do not. That would lower my blood pressure. Because currently, my blood pressure cannot pass the “controlling high blood pressure measure.” AHHHHHHHHHHHHHHH!!!!
Do I think that Congress will get rid of MIPS? I don’t know. There was a lot more pressure to get rid of the Affordable Care Act and that didn’t go as planned, so I doubt it. But if they want to improve it, especially the quality part of it, I have workable ideas. And I will promise to behave…
“To MIPS or not to MIPS, that is the question”
WITH APOLOGIES TO WILLIAM SHAKESPEARE
To MIPS, or not to MIPS, that is the question:
Whether ’tis nobler in the mind to suffer
The slings and arrows of outrageous MACRA,
Or to take arms against a sea of troubled healthcare reform initiatives,
And by opposing end them.
To join an ACO, perchance to retire; there’s the rub:
For I have children in graduate school and a second mortgage on my home,
And not enough in my retirement account.
For who would bear the whips and scorns of EHR vendors,
The payment delays, and the insolence of quality officers,
When he might go to work at the VA or move to Canada
to grunt and sweat under capitated payments or an hourly rate,
But that the dread of something resembling socialized medicine,
From which no healthcare system returns,
makes us rather bear the MIPS we have
Than fly to other payment programs that we know not of?
Thus, an underfunded 401K does make cowards of us all,
And thus, the resolve to chuck it all and go live on the sailboat
Seems like a bad idea – besides the dog is old,
Decisions about the fate of the Quality Payment Program require so much deliberation
That no one, it seems, can make any useful decisions at all.