AMGA: MIPS Exclusion Rules Inhibit Value-Based Care Under MACRA

August 22, 2017 - The American Medical Group Association (AMGA) recently opposed several proposed changes to the Quality Payment Program and its Merit-Based Incentive Payment System (MIPS) for the 2018 performance period. The group particularly expressed concerns over the higher participation thresholds.

“In a well-intentioned effort to make the transition to value-based care as smooth as possible, CMS is delaying this transition,” stated Ryan O’Connor, AMGA’s Interim President and CEO. “Excluding two-thirds of providers from the MIPS program does not meet Congress’ goal to transform Medicare into a value-based purchaser of care.”

In the original MACRA implementation rule, CMS excluded providers from MIPS if they reported $30,000 or less in Part B allowable charges or they serviced 100 or fewer Part B beneficiaries. The provision excluded about two-thirds of Medicare Part B clinicians.

CMS recently proposed to increase the exclusion threshold to $90,000 in Part B allowable charges or less or 200 Part B beneficiaries served or less. The higher threshold aims to “move the program further in the least burdensome manner.”

However, AMGA commented that upping MIPS participation requirements would be counterproductive.

READ MORE: What We Know About Value-Based Care Under MACRA, MIPS, APMs

CMS does not plan to score providers who voluntarily participate in MIPS despite falling below the exclusion thresholds. As a result, clinicians lose an opportunity to participate and earn higher Medicare reimbursement rates. The industry group noted that MIPS could cause up to a 46 percent spread in Medicare Part B reimbursement rates over the next five years.

Excluding two-thirds of Medicare clinicians encourages complacency because lower reimbursement rates prevent clinicians from investing in care delivery improvements. Providers outside of MIPS may also appear less employable and lose their competitive edge.

Therefore, the increased MIPS participation requirements undermine MACRA’s original intent of driving value-based care and reimbursement.

AMGA also stated that eligible clinicians may suffer financially if two-thirds of Medicare clinicians cannot join the budget-neutral program.

In the 2016 proposed MACRA implementation rule, CMS projected positive MIPS payment adjustments to total $1.33 billion in 2019, including the $500 million for exceptional performance bonuses.

READ MORE: Physician Expert, Clinical Documentation Key to MIPS Success

Under the higher MIPS exclusion thresholds, the most recent proposed rule stated that the aggregate positive payment adjustments would be 50 percent less in 2020 compared to the previous year. Positive payment adjustments would reach just $673 million, including the same exceptional performance bonuses.

Since MIPS is budget-neutral, exempting about two-thirds of eligible clinicians would minimize the opportunity for participating clinicians to earn maximum incentive payments. The proposed rule actually stated that no MIPS clinician would earn a positive payment adjustment of more than 1.7 percent despite the maximum reaching 5 percent in 2020.

The average MIPS payment adjustment would be 0.9 percent that payment year.

“The effect of eliminating of two-thirds of eligible clinicians from the MIPS formula is to financially undermine participating clinicians,” the organization wrote. “This problem becomes substantially worse the longer CMS excludes a significant percent of eligible clinicians from MIPS participation because the annual payment rate adjustments accumulate year-over-year.”

Proposals to lower MIPS composite performance score thresholds would also exacerbate the financial challenges, AMGA added.

READ MORE: Key Ways to Succeed Under MACRA’s Quality Payment Program

For the 2018 performance year, CMS proposed to implement a 15-point MIPS performance threshold, up from 3 points during the first transition year. The slightly higher threshold aims to “provide MIPS eligible clinicians an opportunity to achieve a minimum level of success under the program, while gaining experience with reporting on the measures and activities,” CMS stated.

But AMGA pointed out that the impact table in the proposed rule showed that higher MIPS exclusion in conjunction with lower performance score thresholds would result in 94 percent of eligible clinicians earning a positive or neutral payment adjustment.

If the net payments only equate to 0.9 percent and all $500 million of the exceptional performance bonuses are paid out, the total MIPS positive payment adjustments would equal $783 million.

If 94 percent of eligible clinicians qualify for a positive payment adjustment, the mean dollar amount per clinician would be $1,500.

“The combination of an increased exclusion threshold combined with a low CPS [composite performance score] threshold, which CMS admits could be obtained, for example, by reporting no quality measures, forces AMGA to conclude a MIPS program that does not challenge or engage the medical community will not approach the desired quality improvement and spending reduction goals MACRA intends,” the organization argued.

AMGA also questioned quality reporting under MIPS. As one of four MIPS performance categories, eligible clinicians must report on quality measures. They can select from over 250 quality measures to submit to MIPS.

The industry group expressed concerns that the wide range of quality measures that include both process-oriented and topped out metrics would make MIPS composite scores nearly impossible to compare. CMS would not be able to effectively identify high and low-performing clinicians because each eligible clinician would be scored on different quality measures.

CMS should decrease the number of MIPS quality measures and limit the selection to outcome measures that would ideally be claims-based, such as preventable hospital admissions and emergency department visits.

MIPS quality reporting also presents gaming opportunities because CMS proposes to score quality performance based on reporting mechanism. For instance, the highest breast screening score eligible clinicians can earn under the EHR submission method is 73.23, whereas the maximum scores are 87.97 under the registry/Qualified Clinical Data Registry submission approach and 100 under the CMS web interface submission method.

In addition, MIPS quality reporting imposes a significant financial burden on providers, the organization added. The proposed rule stated that the burden of record-keeping and data reporting would total 9.4 million hours in total, with total labor costs equating to $857 million.

The projected financial burden of MIPS reporting in the most recent proposed rule was $184 million more than the estimated total 2018 MIPS bonus payment.

In terms of other potential MIPS changes, AMGA opposed the proposed small practice bonus in the 2020 payment year. CMS intends to award clinicians 5 MIPS composite score points if they work in a practice with 15 or fewer clinicians.

The federal agency designed the bonus to support small practices as they transition to the Quality Payment Program.

But AMGA contended that CMS did not effectively justify the need for a small practice bonus. Practices of 15 or fewer clinicians are less likely to receive a negative MIPS payment adjustment than practices of 16 to 24 clinicians, CMS projected.

CMS also estimated that the aggregate positive MIPS adjustments for groups with 1 to 15 clinicians would be $288 million in the 2020 payment year versus $258 million for practices with 100 more clinicians.

“The data CMS presents does not support the agency's proposed bonus. In addition, awarding five bonus points would allow small practices, CMS admits, to avoid reporting any quality measurements in order to receive the bonus,” the letter added. “AMGA cannot support the proposed bonus absent evidence justifying it.”

Instead, CMS would encourage small practices to be competitive in MIPS by joining a virtual group and reporting more quality measures than required to earn additional points.

The industry group also called on CMS to reconsider several Advanced Alternative Payment Model changes, including qualifying participant determinations at the individual eligible clinician level and the lack of qualifying Medicare Advantage models.