MIPS - Learn to live with it

House Committees on Energy & Commerce and Ways & Means
March 20, 2015
Working Framework of SGR Package

Repeal and Replace Medicare Physician Payment System. The legislation
repeals the flawed SGR formula and replaces it with HR 1470, SGR Repeal
and Medicare Provider Payment Modernization Act (replaces SGR with MIPS,
the Merit-based Incentive Payment System)

Children's Health Insurance Program (CHIP). This provision preserves and
extends CHIP, fully funding the program through September 30, 2017.

Medicare, Medicaid, and Other Health Extenders. The legislation extends
all of the extenders included in the Protecting Access to Medicare Act
of 2014 (PAMA, the most recent SGR patch) in addition to funding for
Community Health Centers through 2017.

Other Medicare Reforms.1) Medicare DMEPOS Competitive Bidding
Improvement Act (HR 284). (2) The Protecting Integrity in Medicare Act
(HR 1021).

Savings.

(1) Income-related Premium Adjustment. Starting in 2018, this policy
would increase the percentage that beneficiaries pay toward their Part B
and D premiums in two income brackets (roughly 2 percent of
beneficiaries): for individuals with income between $133.5-160K
($267-$320K for a couple), the percent of premium paid increases from 50
percent to 65 percent. For those with income between $160-214K ($320-
$428K for a couple), the percent increases from 65 percent to 75 percent.

(2) Medigap Reform. The proposal limits first dollar coverage on certain
Medigap plans by prohibiting plans from covering the Part B deductible.
Change applies only for future retirees starting in 2020.

(3) Increase Levy Authority on Payments to Medicare Providers with
Delinquent Tax Debt.

(4) Hospital Update. Under current law, hospitals will receive a 3.2
percentage point adjustment in addition to their base payment rate in
FY18. This policy would phase-in this update incrementally.

(5) Additional Medicaid DSH Savings.

(6) 1 Percent Market Basket Update for Post-Acute Providers

http://waysandmeans.house.gov/uploadedfiles/bipart_topline_summary-032015_final2.pdf

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The Wall Street Journal
March 22, 2015
What Measures Should Be Used to Evaluate Health Care?
By Melinda Beck

There's little agreement among patients, providers and insurers

http://www.wsj.com/articles/what-quality-measures-should-be-used-to-evaluate-health-care-providers-1427079654

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Health Affairs Blog
January 24, 2014
Primum Non Nocere: Congress's Inadequate Medicare Physician Payment Fix
By Jeff Goldsmith

With this legislation, Congress is preparing yet again to enshrine in
statute another payment strategy that is both unproven and highly
controversial.

The proposed legislation casts in concrete an almost laughably complex
and expensive clinical record-keeping regime, while preserving the very
volume-enhancing features of fee-for-service payment that caused the SGR
problem in the first place. The cure is actually worse, and potentially
more expensive, than the disease we have now.

If we're not sure new advanced payment schemes actually work, if we
haven't actually gotten them right, then we have no business compelling
or incenting 680 thousand practicing physicians to use them. We're not
going to get clinical practice where we want it to go with an elaborate,
individualized operant conditioning schedule with four domains and sixty
eight "core measures", and billions more spent on the IT systems and
clerical support to document them. We need to reward teamwork, not
box-checking.

It isn't just physicians that should be guided by Hippocrates' maxim,
"First Do No Harm," but our policymakers as well.

http://healthaffairs.org/blog/2014/01/24/primum-non-nocere-congresss-inadequate-medicare-physician-payment-fix/

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Comment by Don McCanne

We're there. The SGR extension expires March 31, and Congress is leaving
for a two week recess this Friday, March 27. Not only is there strong
bipartisan Congressional support for HR 1470, the SGR repeal and
replacement act, but there is also overwhelming support from the AMA and
other physician societies and from other influential interest groups
such as Families USA. The bill will pass this week.

The last two Quote of the Day messages have discussed some serious
defects in this legislation, especially the problems with the
Merit-based Incentive Payment System (MIPS). But that part of the bill
is a given. What is new today is the one page summary of the intended
amendments that will be added before enactment of the bill (see "Working
Framework of SGR Package," above).

Two items in these proposed amendments are of particular concern: 1)
Means-testing of Medicare Part B and Part D premiums, and 2) Prohibiting
Medigap plans from covering the Part D deductible.

Under means-tested premiums, higher-income individuals will be required
to pay larger premiums, undermining the support of this influential
group for the traditional Medicare program. Since they will be paying
higher premiums, many likely would prefer to select their own coverage
from a market of private Medicare plans - a goal of those supporting
privatization of Medicare through the premium-support model of reform.
Thus this provision would be a significant incremental step towards
privatization.

Prohibiting Medigap plans from covering Medicare Part B deductibles
expands the implementation of consumer-directed approaches to financing
health care. It advances the conservative agenda of requiring more
personal responsibility on the part of patients, often expressed by the
repulsive "skin in the game" rhetoric. Much has been written about the
potential adverse consequences of deductibles, but the more ominous
portent of this measure is that it establishes the principle that all
health care must conform with the consumer-directed model. As we have
seen, the use of ever higher deductibles is rapidly expanding in
employer-sponsored plans, and this opens the door for the same rapid
increase in cost sharing to occur with Medicare.

But back to the basic bill - using the MIPS to replace the SGR. In the
last two Quote of the Day messages it was pointed out what an
administrative nightmare MIPS would bring us. What should be
particularly alarming is that these new required administrative
procedures have not been shown to either significantly decrease the
volume of medical services, or improve quality - supposedly the two
goals of payment reform.

As Jeff Goldsmith states about last year's version of the same policies,
"The proposed legislation casts in concrete an almost laughably complex
and expensive clinical record-keeping regime, while preserving the very
volume-enhancing features of fee-for-service payment that caused the SGR
problem in the first place. The cure is actually worse, and potentially
more expensive, than the disease we have now."

Tune in to C-Span this week for the latest chapter in their epic fiction
series: Democracy in America.