qotd: No more SGR, but… here you go!

CMS
December 18, 2015
CMS Quality Measure Development Plan: Supporting the Transition to the
Merit-based Incentive Payment System (MIPS) and Alternative Payment
Models (APMs) (DRAFT)

Building on the principles and foundation of the Affordable Care Act,
the Administration announced a clear timeline for targeting 30 percent
of Medicare payments tied to quality or value through alternative
payment models by the end of 2016 and 50 percent by the end of 2018.
These are measurable goals to move the Medicare program and our
healthcare system at large toward paying providers based on quality,
rather than quantity, of care.

The passage of the Medicare Access and Children's Health Insurance
Program (CHIP) Reauthorization Act of 2015 (MACRA) supports the ongoing
transformation of healthcare delivery by furthering the development of
new Medicare payment and delivery models for physicians and other
clinicians. Section 102 of MACRA requires that the Secretary of Health
and Human Services develop and post on the CMS.gov website "a draft plan
for the development of quality measures" by January 1, 2016, for
application under certain applicable provisions related to the new
Medicare Merit-based Incentive Payment System (MIPS) and to certain
Medicare alternative payment models (APMs).

Merit-Based Incentive Payment System

Measures for use in the quality performance category are a specific
focus of the MDP. MIPS will build upon existing quality measure sets
from the Physician Quality Reporting System (PQRS), Value-based Payment
Modifier (VM), and Medicare EHR Incentive Program for Eligible
Professionals (EPs), commonly referred to as Meaningful Use.

To fill identified measure and performance gap areas, CMS will expand
and enhance existing measures to promote alignment and harmonization in
the selection of measures and specifications, while concurrently
developing new (de novo) measures according to priorities described in
Section IV.

To accelerate the alignment of quality measurement and program policies,
MACRA sunsets payment adjustments for PQRS, VM, and the EHR Incentive
Program and establishes MIPS.

Alternative Payment Models

MACRA establishes incentive payments for EPs participating in certain
types of APMs. MACRA requires quality measures used in APMs to be
comparable to the quality measures used in MIPS; therefore applicability
of candidate measures to support a variety of future APMs is an
important element of this MDP.

From the Conclusion

CMS is committed to reducing provider burden through the use of measures
aligned across federal and private-payer quality reporting programs. We
stress harmonization of data elements and specifications among measure
developers, whose cooperation and sharing are essential to creating
aligned measures. Toward that end, we also intend to leverage the
optional pre-rulemaking process and MAP review for MIPS and to
participate with other stakeholders in efforts that promote measure
alignment. This draft MDP acknowledges the associated challenges and
identifies opportunities for measure developers to share information to
reduce duplication of efforts.

CMS Quality Measure Development Plan (MDP) - 61 pages:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Draft-CMS-Quality-Measure-Development-Plan-MDP.pdf

MACRA, MIPS, APMs, MDP, and request for public comment:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

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Comment by Don McCanne

Physicians celebrated the passage of the Medicare Access and Children's
Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA)
since it brought an end to the much despised SGR (Sustainable Growth
Rate) method of adjusting Medicare payment rates. Though SGR was rarely
implemented, it carried forward a massive deficit that would have
required major reductions in Medicare payment rates. Besides, MACRA
included the reauthorization of the Children's Health Insurance Program.
The trade-off, which was largely ignored, was the requirement to
establish the Merit-based Incentive Payment System (MIPS) and
Alternative Payment Models (APMs). CMS has now released a draft of the
Quality Measure Development Plan for transitioning to MIPS and APMs.

Perhaps the main reason that physicians, who happened to be aware of
MIPS and APMs, were not concerned is that they replaced the Physician
Quality Reporting System (PQRS), Value-based Payment Modifier (VM), and
Medicare EHR Incentive Program for Eligible Professionals (EPs),
commonly referred to as Meaningful Use. Many thought that this would
bring efficiency to existing programs by coordinating them under MIPS.

There are three reasons that physicians should be concerned. The first
is that these programs are not simply now coordinated, they are expanded
and enhanced with the development of new de novo measures. Think of what
that means for new administrative burdens added to existing ones.

Second, some physicians no doubt thought that they could escape the MIPS
burdens since MACRA would allow physicians to move into Alternative
Payment Models (APMs) - accountable care organizations, patient centered
medical homes, or whatever. Don't celebrate yet. MACRA requires that the
quality measures used in APMs to be comparable to the quality measures
used in MIPS. MIPS is now an obligation no matter where you turn.

Third, and most important of all, is that the PQRS, VM, and the EHR
Incentive Program were highly flawed programs adding significantly to
the excessive administrative burden that characterizes the U.S. health
care system, while having a relatively negligible impact on improving
health care quality. The proper policy step should have been to send
these programs back to the drawing boards, and then when it became
obvious that there was no there there, locking them in storage forever.
The worst policy decision would be to expand these programs and force
them on everyone, but that is precisely what they did.

Quality is not achieved by playing the alphabet games, with nominal
penalties and rewards. It is achieved by instilling efficiency and
equity into our health care delivery system. A well-designed single
payer system does that. A paper written by a team led by Gordon Schiff,
and published in JAMA two decades ago, defines quality and describes how
it can be achieved by implementing a single payer national health program:

A Better-Quality Alternative: Single-Payer National Health System Reform
JAMA, September 14, 1994, Volume 272 Copyright 1994, American Medical
Association

http://www.pnhp.org/publications/a_better_quality_alternative.php