DCMedical News: January 9, 2018
DCMedical News
Washington, D.C.
Tuesday, January 9, 2018
THE BIG STORY TODAY IN HEALTH CARE
MedPAC meets this Thursday and Friday, January 11 and 12. Can’t make it? We will be there for you.
The Thursday morning session (agenda here) is given over to progress reports (Medicare Advantage, Part D), the afternoon Thursday to “assessing payment adequacy and updating payments.” The enterprises whose payment adequacy are to be examined include inpatient and outpatient hospital services, physician and other health professional payments, followed by ambulatory surgery, dialysis and hospice. At the end of the day comes a report on “increasing the equity” among post-acute care services, that is, balancing financial incentives so that the utilization of skilled nursing, home care, IRFs (Inpatient Rehabilitation Facilities) and LTACs (Long Term Acute Care hospitals) bears some relationship to the clinical needs of the patients in post-acute settings.
The final report Thursday is on the effects of the Hospital Readmissions Reduction Program, timely, in view of research indicating that Bethesda-set limits on readmission, and penalties for hospitals exceeding those limits, have begun killing patients who, in fact, apparently needed to be readmitted to a hospital. (Unintended consequences, e.g. here and here.)
The lesser program, on Friday, has a report on telehealth and the Medicare program (a report mandated by the 21st Century Cures Act, but telehealth losing steam), physician fees and ambulatory evaluation and management services (fussing about boosting E&M fees to offset procedure-related income of specialists), and a status report on Medicare Accountable Care Organizations (some make money, some don’t, nobody counts the cost of diverting extraordinary amounts of attention, as well as physician and executive time, result: meh).
DOCTORS
Thursday in the sleepy post-prandial hour (1:30-2:30) MedPAC will tackle MIPS. In the agenda, a highlighted portion of the physician payment update is entitled “Moving beyond the Merit-based Incentive Payment System.” (MIPS is an incentive payment rubric from MACRA, the Medicare Access and CHIP Reauthorization Act of 2015.)
MedPAC has circled around this issue for months, going back to its January, 2017 meeting (transcript here). A discussion and draft to replace MIPS was raised in the September meeting (transcript here) and questions about the staff recommendation were addressed in the October meeting (transcript here), November (here) and December (here).
In December, discussion of MIPS is recorded beginning on pg. 10 of 456 of the transcript. CMS staff (which is separate from the staff of MedPAC) estimates the reporting burden for physicians producing MIPS-related information to be $1 billion per year, although no such figure was mentioned in the lead-up to passage of MACRA. In a display of candor, possibly motivated, however, by their desire to move to a new system, MedPAC staff report (pg. 11) that “. . . it’s unlikely that all of this information is useful. The measures are variable in their clinical appropriateness and association with meaningful outcomes . . And [names of measures] have not been shown to be associated with high-value care . . .There is the perennial issue of small sample sizes for individual clinicians, and this is exacerbated by MIPS’ design and action taken by CMS. Each clinician will get a composite MIPS score reflecting a different mix of measures. By construction, it’s not comparable across clinicians. But, nevertheless, CMS will move substantial funds around each year based on these non-comparable scores.” (emphasis added).
Staff go on to indicate that small amounts of money will be involved in the first two years of MIPS quality awards, but that “In years three and later, because CMS will . . . set the performance threshold at the mean or median of scores, small differences in MIPS scores will be blown up into potentially massive differences in payment adjustments.”
Some discussion during the December meeting seemed to indicate that such massive differences had already begun to appear, some groups prospering, most not, irrespective of demonstrable change in “quality” scores. The staff worried that, as “winners” emerged in the scoring, they would defend the system, while “losers” would refuse to participate. Of course, the staff has yet another new performance measurement program in mind, seemingly unwilling or unable to declare defeat for the process of centralized bureaucratic scoring, intent instead on finding the right scorekeeper.
EVENTS & PUBLICATIONS, MEETINGS AND READINGS
The Kaiser Foundation is ready to take our minds off the dismal present, and raise our sights to “Health Reform 2020,” beginning, in one of those coincidences, about the same time Thursday the MedPAC meeting begins.
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Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com