The Medicare Payment Advisory Commission (MedPAC) Oct 5-6 met to discuss a wide variety of Medicare issues, including next steps for the Merit-based Incentive Payment System (MIPS), reports on telehealth in the commercial insurance space, and Medicare’s hospital value incentive programs.
MedPAC staff discussed challenges with the current MIPS system, chiefly provider burden and the overall complexity of the program, as well as concerns with the measures used and how providers are scored. Commission staff noted that MIPS is structured to maximize provider scores, which may lead to score compression and a limited ability to detect performance levels.
Further, because clinicians can choose their own measures, staff noted that the resulting MIPS score is inequitable across clinicians. Because of these and other challenges, MedPAC staff put forth a policy option that would eliminate MIPS and establish a new voluntary value program. The option would eliminate many of the MIPS reporting measures; instead, all clinicians would have a percentage of fee schedule payments withheld. Clinicians could elect to be measured with large entity of peers, join an advanced alternative payment model, or make no election (and lose the withhold amount). However, much discussion centered around what a replacement option would look like, and how it would address the existing problems with the program. The commission called for continued discussion and more detailed draft recommendations at the December meeting
Building on discussions at previous meetings, commission staff presented two additional reports on telehealth that were mandated by the 21st Century Cures Act. In the first presentation, staff reviewed coverage policies from a variety of managed care organizations (MCOs) noting significant variation between the plans in how telehealth is delivered and covered. They found that 94 percent of the MCOs in their sample covered some degree of telehealth services, and the most commonly covered services were basic evaluation and management visits, mental health services, and pharmacological management.
The second report focused on perceptions and use of telehealth in site visits and focus groups. The commission found that the most success in a telehealth modality was through telestroke interactions. However, there is generally no separate reimbursement for this interaction, a common challenge in telehealth. The commission discussion centered on the low utilization of telehealth, particularly among Medicare beneficiaries, and concerns about the broad definition of telehealth. The commission intends to continue the discussion of telehealth at the November meeting.
MedPAC staff outlined and sought feedback on a proposal to redesign Medicare's hospital value-based programs. The proposal – Hospital Value Incentives Program (HVIP) – would merge the Hospital Readmissions Reduction Program (HRRP) and the Hospital Value-Based (VBP) Program and eliminate the Inpatient Quality Reporting Program (IQRP) and the Hospital-Acquired Condition Reductions Program (HACRP).
In place of these programs, the HVIP would score four quality and value measures – readmissions, mortality (stay + 30 days), Medicare spending per beneficiary, and patient experience (HCHAPS). There would be clear, absolute performance targets set prospectively and measures would account for social risk factors. HVIP is projected to be budget neutral to current programs, but it was acknowledged that it may not be in all years.
MedPAC also proposes that hospital infection rates could be excluded from the HVIP, as there tend to be greater false negatives and false positives than mortality and readmissions measures and hospitals should not be penalized for proving detection of infection rates. However, hospitals would still be required to report infections to the CDC as a condition of participation in Medicare and work to reduce rates.