The commission listed six recommendations for refining the U.S. Centers for Medicare and Medicaid Services (CMS) Quality Payment Program's advanced alternative payment models (APMs). It also noted a flaw in the Merit-Based Incentive Payment System (MIPS) structure, which it believes is too reliant on clinician-reported quality measures.
MACRA's complexity makes carrying it out a challenge, according to the commission.
"Our discussion is intended to assist in thinking through the implementation of this legislation and to help move the Medicare program from one oriented toward [fee-for-service] payment to one that encourages delivery system reform oriented toward payment for value," MedPAC wrote.
All about APMs
MACRA eliminated Medicare reimbursement changes using the sustainable growth rate (SGR) formula and called for the establishment of payment policies based on healthcare quality, rather than the fee-for-service (FFS) system that has long been in place in the U.S. The legislation is meant to consolidate what has been a patchwork of alternative payment models and quality incentive initiatives into a single framework called the Quality Payment Program, which consists of two paths: APMs and MIPS.
In its report, MedPAC offered some particular advice regarding these two pathways, starting with its basic principles for APMs:
- In the commission's view, incentive payments should not be awarded for simply participating in an APM, but should be contingent on quality and spending performance.
- The APM should be at financial risk for total Part A (hospital care) and Part B (doctors' services) spending. "Making [APMs] responsible for total spending and patient outcomes might help move the FFS payment system from volume to value, encourage care coordination, and more broadly reform the delivery system," MedPAC wrote.
- The APM should be responsible for a beneficiary population sufficiently large to detect changes in spending and quality.
- The APM should have the ability to share savings with beneficiaries. "Beneficiary involvement would help [APMs'] efforts to control spending and improve quality," the commission wrote.
- To the extent that an APM is at two-sided risk for total Part A and Part B spending, it should be given relief from some of Medicare's existing regulations designed to prevent excessive service use.
- Each APM should have a single body, such as a governing board, responsible for assuming risk, enrolling clinicians, and distributing bonuses or penalties.
Almost all of these suggestions can be executed within the context of the law, although a few will probably require changes to the law, MedPAC Executive Director Mark Miller, PhD, said in a press conference.
"That's something the commission will want to discuss for the next report cycle, whether to make additional recommendations to Congress," he said.
Making sense of MIPS
MedPAC expressed concerns about the MIPS structure, stating that quality should be based on population-based outcomes such as readmissions, mortality, and patient experience rather than clinician-reported process measures.
"We would look for much more outcomes-based, population-based, aggregate types of measures," Miller said. "You can do a lot of measurements in MIPS but have large percentages of physicians indistinguishable from each other because individual performance is hard to differentiate."
In any case, CMS should focus on improving the value of its quality programs, in part by minimizing the burden of quality reporting and maximizing the use of claims data, which the Medicare program already collects, the commission wrote.
"The right incentives will result in delivery system reforms that further the goal of controlling Medicare spending and improving quality while preserving or improving access for Medicare beneficiaries," it concluded.
The full report can be found here.
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