As part of its campaign to fix the unsustainable Medicare physician payment system, the AMA is outlining the need to give doctors access to a wide range of timely information to identify opportunities to improve health outcomes, reduce variations in care delivery or eliminate avoidable services—all steps that can lower costs for patients and the Medicare program.
To be successful in advancing value-based care, physicians in Medicare’s Merit-based Incentive Payment System (MIPS) need timely access to that kind of data. While Congress recognized the critical importance of data sharing with physicians in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) statute that created MIPS by requiring timely performance feedback, the Centers for Medicare & Medicaid Services (CMS) has dragged its feet in meeting this statutory obligation.
CMS now gives physicians their annual feedback report six to 18 months after their performance was measured. The agency has never provided Medicare claims data to physicians, even though the requirement took effect in 2018, notes the AMA’s two-page explainer on MIPS data problems (PDF).
The AMA is leading the charge to reform the Medicare payment system, which is the AMA’s top advocacy priority.
Learn how physicians can take part in the fight to reform Medicare on behalf of your patients and practices at the AMA's Fix Medicare Now website.
Experience-report trend data lacking
CMS releases an annual overview of data collected through its Medicare Quality Payment Program (QPP), including MIPS and alternative payment model data, and the number of physicians who will receive a MIPS bonus or penalty. But the data provided by this QPP Experience Report is of limited use, the AMA explains.
For example, the same physician can be counted multiple times if they bill for services through multiple organizations. And a physician can have a low MIPS score for one practice and a high MIPS score for another. On top of that, CMS does not break down performance by physician specialty, site of service, or the type of reporting.
The report also fails to show any longitudinal trends about whether quality or cost are getting better or worse, nor does it provide a complete picture of what made a physician or group practice successful in MIPS.
The AMA’s own analysis of several MIPS data files found that they are incomplete and inconsistent. As a result, it is difficult to drill down into the data to better understand how small practices and rural practices, for example, are performing in MIPS and why this might be the case. Ensuring that data is accurate is critically important to ongoing efforts to understand and improve this program.
It's essential that Medicare payment concerns like these get sorted out so that physicians can keep providing care for the millions of American who rely on the system.
“My fear is that without major Medicare reform, there will simply be nothing left to cut,” said Portland, Oregon, bariatric surgeon Kevin Reavis, MD. He is among the AMA members who have taken time to share their firsthand perspectives on the impact of unsustainable Medicare physician payment in interviews with the AMA. “The system is in the process of collapsing and my fear is that if and when it occurs, it will be something we won’t be able to resurrect.”
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AMA outlines a new approach
The AMA has long been concerned about the undue administrative burden placed on physicians subjected to MIPS reporting requirements, the program’s lack of improvement in patient outcomes and quality of care, and the limited scope of quality measures for specialists.
With substantial input from national medical specialty societies and physicians across the country, the AMA has developed a statutory proposal to replace the MIPS tournament model of payment adjustments with a more sustainable approach tied to annual payment updates, give the Centers for Medicare & Medicaid Services incentives to share data with physicians, and improve the measures.
The MIPS replacement, called the “Data-Driven Performance Payment System,” would freeze the performance threshold to avoid a penalty at 60 points for at least three years and call for a study to improve the threshold methodology. It would also eliminate the win-lose style payment adjustments that include a maximum penalty of negative 9% and instead link performance in MIPS to a percentage increase or decrease of the annual update, which would better align across Medicare payment programs, such as the Hospital Inpatient Quality Reporting System.
Importantly, it would also exempt from penalties physicians who do not receive at least three quarterly feedback reports during the performance period. This new system would replace steep penalties that are unevenly distributed, ensure timely access to data, reduce unnecessary administrative burden, and increase the clinical relevance of the program to physicians and their patients.
More details about this proposed replacement for MIPS are in the AMA’s response to the Senate Finance Committee (PDF) white paper on bolstering chronic care in Medicare Part B.
Catch up on the Medicare basics
While the AMA is working relentlessly to build understanding on Capitol Hill about the unsustainable path the Medicare payment system is on, preventing further cuts means getting to the root causes of what’s wrong with Medicare physician payment.
That is why the AMA created the Medicare Basics series, which provides an in-depth look at important aspects of the Medicare physician payment system. With these six straightforward explainers, policymakers and physician advocates can learn about key elements of the payment system and why they are in need of reform.
Visit AMA Advocacy in Action to find out what’s at stake in reforming Medicare payment and other advocacy priorities the AMA is actively working on.
— Senior News Editor Kevin B. O’Reilly wrote an earlier version of this article.
