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AMGA Seeks End of MIPS Exclusions to Promote Value-Based Care

MIPS exclusions mean limited incentives for high-performing medical groups to invest in and implement new health IT.

MIPS and the Quality Payment Program

Source: Thinkstock

By Kyle Murphy, PhD

- AMGA is calling on Congress to implement MACRA and the Quality Payment Program it introduced fully, beginning with the elimination of exclusions from the Merit-based Incentive Payment System (MIPS) that exempted more than half of eligible clinicians.

“MIPS was designed as a viable transition tool to value-based payment in the Medicare program, where providers would be rewarded for their investments in health information technology (IT), care management processes, and people,” wrote American Medical Group Association (AMGA) President & CEO Jerry Penso, MD, MBA. “However, the Centers for Medicare & Medicaid Services (CMS) has not implemented MIPS as Congress intended.”

The organization representing medical groups drew special attention to the budget-neutral provision of the Medicare Access and CHIP Reauthorization Act (MACRA) that means negative payment adjustments for some become positive payment adjustments for others.

“Under the MIPS program, providers have the opportunity to earn an annual adjustment to their Medicare Part B payments based on their performance starting in 2019, with a positive or negative adjustment range of 4%. That range eventually increases to 9% in 2023,” Penso reiterated.

By excluding nearly 60 percent of eligible providers from the pool, the gains for high-performing medical groups were not as significant as planned.

“For example, high performers are estimated to receive an aggregate payment adjustment in 2019 of 1.1%, compared to a potential 4% allowed under the statute,” Penso observed. “In 2020, CMS expects a 1.5% payment adjustment for high performers, compared to a potential 5% adjustment provided for in the law. In 2021, CMS expects a 2% payment adjustment for high performers, but the statute suggests a potential 7% adjustment.”

If the trend of exclusions continues, diminishing returns are unlikely to drive participation in a program designed to steer providers toward value-based care generally and advanced alternative payment models specifically.

“These insignificant payment updates fail to reward providers for superior performance in the MIPS program and provides nominal return on investments. Unfortunately, MIPS has devolved into an expensive regulatory compliance exercise with little to no impact on quality or cost. Policymakers should no longer exclude providers from MIPS,” Penso argued.

In the spirit of inclusiveness, AMGA has called on Congress to lower threshold for participating in Advanced APMs, the second path of the Quality Payment Program and the goal of MACRA as far as tying payment to value.

“To qualify for the program, providers must meet or exceed minimum revenue thresholds from APMs, or minimum numbers of Medicare beneficiaries in these models,” wrote Penso. “For example, in 2019, 25% of a provider’s Medicare revenue must come from APMs. In 2021, 50% of revenue must come from APMs. This threshold increases to 75% in 2023.”

According to AMGA, this approach is unlikely to meet with success.

“However, these APM requirements are unlikely to be met and will not attract the critical mass of physicians and medical groups necessary to ensure success,” Penso claimed. “This is due to a dearth of commercial risk products and limited Medicare Advance APM options. Congress must eliminate these arbitrary thresholds so that more providers can make the transition to value as envisioned under MACRA.”

Also tied to MIPS and APMs is the matter of data access, which AMGA has identified as a pain point for medical groups.

“Providers have repeatedly expressed concern with the lack of access to timely Medicare and commercial payer administrative claims data,” Penso added. “In order to manage a patient population, providers need data to ensure the most effective course of action in improving health outcomes. At the moment, access to this data is often denied or limited. Congress should require federal and commercial payers to provide access to all administrative claims data to healthcare providers in value-based arrangements.”

AGMA has also identified the need for greater data standardization to ensure that providers avoid wasting of time and resources preparing data sets for analysis and interpretation.

“Currently, medical groups submit data to different insurance companies in different formats, creating a massive administrative burden and a diversion of resources from providing care to reporting data. Congress should require federal and commercial payers and providers to standardize data submission and reporting processes,” said Penso.

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