Excluding more doctors from Medicare’s MIPS 'a step backwards,' says policy expert

A proposed rule that exempts even more doctors from MACRA is a bad idea, according to one policy expert.

Under a proposed rule, even more doctors and other clinicians will be excluded from participating in the Medicare payment system created under MACRA.

While that may be good news for doctors who don’t have to meet the requirements of participation in MACRA’s Merit-Based Incentive Payment System (MIPS), the policy decision creates problems, writes David Introcaso, Ph.D. an independent health care research and policy consultant, in Health Affairs.

The proposed rule released last month by the Centers for Medicare & Medicaid Services expands the low volume threshold that exempts practices with a small number of Medicare patients from the program. The change would exempt more than 585,000 eligible clinicians from the program and its reporting requirements, as the threshold increases to exclude clinicians with less than $90,000 (the old limit was $30,000) in Part B charges or fewer than 200 Part B beneficiaries (previous limit was 100).


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Introcaso, who does regulatory policy analysis for the American Medical Group Association, an organization that opposes any slowdown to the transition to value-based care, writes that the proposed change to triple the exclusion dollar amount and double the number of beneficiaries has some negative implications.

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Impact on doctors excluded. Excluding two-thirds of eligible MIPS participants “undermines MACRA’s intent,” he says, when there’s no evidence from CMS that smaller practices would not be competitive and therefore more likely to receive a negative payment adjustment. It denies small practices the opportunity to succeed and earn annual payment increases that can be substantial over time, he argues.

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Impact on doctors included. For those doctors and clinicians who are required to participate, the exclusion has a negative impact, he says, by reducing the pool of dollars for those who show a positive performance by 50%.

Effect on Medicare beneficiaries. Since MACRA is intended to help or create an incentive for eligible clinicians to provide high-quality care that is more spending efficient, it doesn’t help beneficiaries to exclude providers from the program, he says. 

“In sum, delaying or denying MIPS participation for two-thirds of eligible clinicians is a step backward,” he writes.

Another idea put forth in the proposed rule—establishing virtual groups as a way to give solo practitioners and small-group practices a way to participate in quality reporting—also has been met with skepticism from some providers, according to Physicians Practice. Policy analysts and consultants told the publication that there are lots of unanswered questions and compressed timelines for many physicians to feel comfortable participating in a virtual group next year.

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