Physicians to CMS: Connect MIPS Value Pathways to patient care
The AMA and 31 national medical specialty societies urged (PDF) the Centers for Medicare & Medicaid Services (CMS) to overhaul existing and candidate Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) by grouping measures based on chronic health condition, episode of care or subspecialty.
This would ensure that quality of care is maintained or improved as costs are maintained or reduced, assess the value of patient care, and make meaningful comparison information available to patients.
The letter called on CMS to ensure there are sufficient quality measures, to remove arbitrary quality measure scoring rules, and to incorporate private sector-funded and specialty-led qualified clinical data registries, which offer continuous feedback to physicians, leverage digital sources and advance a learning system with a broad focus that can readily adapt and grow over time. CMS must also remove the problematic Total Per Capita Cost measure, which holds physicians accountable for all Medicare inpatient and outpatient spending despite physicians’ inability to control costs unrelated to the conditions they treat. The letter urges CMS to remove the population health measure requirement, which adds additional complexity with its own burdensome and uneven scoring rules without ensuring it is properly targeted at improving the patient’s outcomes. Finally, the letter strongly urges CMS to keep MVPs optional to avoid adding even more administrative and regulatory burden on physician practices.
New approach needed for MIPS cost measures
In response to survey questions about developing the next wave of cost measures for potential inclusion in MIPS, the AMA urged CMS and its contractor, Acumen LLC, to develop cost measures based on conditions or episodes of care where there is variation in spending that is within the control of the physician. Instead, CMS looks at gaps in cost measures based on service or specialty. This does not tell the public whether those clinical conditions or episodes of care include unnecessary costs that could be reduced by changes in ordering, prescribing, care coordination or other activity by the physician. The AMA also urged CMS to carefully consider feedback from the national medical specialty societies.
Additionally, the AMA expressed concern with CMS’ intention to develop value measures using claims data, which gives no insights into patient-specific or clinical data. As a result, there is little to no ability to adjust for disease severity or a patient’s lack of access to transportation, for example. Moreover, there are significant attribution and risk adjustment problems with the existing episode-based cost measures that we think would be exacerbated by developing value measures using claims data. Claims data alone do not provide the level of granularity needed to move the needle on quality.
AMA responds to 2026 Medicare Advantage proposals
In a comment letter (PDF) responding to CMS proposals for the 2026 Medicare Advantage (MA) and Part D prescription drug programs, the AMA expressed strong support for the proposed expansion of Part D coverage for FDA-approved anti-obesity medications, particularly glucagon-like peptide-1 (GLP-1) receptor agonists. Comments note that the GLP-1 medications represent significant advancements in obesity treatment but remain inaccessible to many patients due to their prohibitive costs and lack of insurance coverage.
AMA comments also focus on the need to remove MA and Part D plan utilization management barriers including prior authorization. Citing recent reports from the American Society of Addiction Medicine, FDA and the NIH National Institute for Drug Abuse, the letter strongly advocates removing prior authorization and quantity limits for buprenorphine to treat opioid use disorder. It also underscores the importance of greater transparency in plans’ use of internal coverage criteria, urging CMS to finalize its proposal requiring plans to provide data at the item/service level on prior authorization approvals, denials, and processing times.
The AMA urges CMS to finalize its proposal that MA plan provider directory data be submitted in a format allowing it to be added to the Medicare Plan Finder. This policy will allow people with Medicare to easily determine if their physician is part of a plan’s network when they are exploring plan options. The AMA letter welcomes CMS’ proposal to promote informed choice regarding Medigap plans, which will require MA agents and brokers to explain that beneficiaries have a 12-month trial period during which they can disenroll from MA and return to traditional Medicare and purchase a Medigap policy with guaranteed issue rights, but that outside of this trial period, they will no longer have these guaranteed issue rights so that their health conditions may affect their Medigap eligibility and premiums. The AMA recommends that agents and brokers also must inform beneficiaries about state-specific Medigap guaranteed issue rights and explain how Medigap premiums may increase based on age and/or health conditions after the trial period.
More articles in this issue
- Feb. 7, 2025: Advocacy Update spotlight on the AMA National Advocacy Conference
- Feb. 7, 2025: Medicare Payment Reform Advocacy Update
- Feb. 7, 2025: State Advocacy Update
