MIPS: Big goals, unanswered questions

MACRA has big goals, lots of questions.

MACRA has some big goals: improving quality of healthcare, controlling spending and maintaining access to care.

But there’s also a big question: Can the new Medicare physician payment system deliver on those goals? That's the question the authors of a perspective piece in The New England Journal of Medicine ask.

The Quality Payment Program that implements the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) launched on Jan. 1. It’s expected that most doctors and healthcare clinicians that participate in the program will do so under the Merit-Based Incentive Payment System (MIPS), by a seven to one ratio from those who can choose a parallel payment pathway: advanced alternative payment models (APMs).

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Prior attempts to modify physician payment didn’t meet MACRA’s lofty goals, leaving the question of whether MIPS can change that dynamic, wrote Eric C. Schneider, M.D., and Cornelia J. Hall, of The Commonwealth Fund and Harvard University.

But they cautioned that MIPS may spark unintended consequences for physician practices. For instance, some worry that it may force the merger of smaller practices into larger ones or encourage further acquisition of practices by hospitals and healthcare systems.

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MIPS will change practices’ business model from one attuned to fee-for-service and generating services to one generating payment adjustments based on a performance score, they note. The Centers for Medicare & Medicaid Services (CMS), which oversees MACRA, will need to watch for results.

“Evaluating the MIPS on the basis of measured quality, payment adjustments, and financial effects alone may be insufficient, especially in the short term. CMS should monitor for other signs of disruption and progress—effects on access to care, clinician morale, patient experience, practice consolidation, migration to APMs and progress toward innovative care models and team-based care,” they write.

Numerous factors will influence practices’ financial success and affect decisions about how to participate and the performance level they can achieve, according to the pair. They include local factors such as competition and the presence of dominant hospitals or insurers as well as trends in utilization.