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Thursday, April 19, 2018

Physicians Disagree with Merit Based Incentive Plan . MIPS

ACP calls for revision of physician performance measurements

In an effort to restrain  costs Medicare has implemented a new system designed to do away with procedural based billing, also known as fee for service (FFS).  Physicians have previously submitted a bill to patients that are encoded by a  CPT code. (current procedural terminology)

It has been posited that this methodology encourages upcoding, or increasing the number of procedures as an incentive to increase income by physicians or others.

During the last five years Medicare has proposed several changes to accomplish improved quality of health care. Their early proposals were fraught with inaccuracy and were embedded with other suggestions including health information technology,  

The present and resulting algorithm, called MIPS is the outgrowth of heated and repeated negotiations between CMS and physician organizations, including the AMA, ACP, FACP and most ot her specialty groups. During the past 20 years, a calculated decrease in physician fees was calculated but was never applied at the end of each fiscal years. The increases were deferred each year, until the decrease became an impractical reality and would have bankrupted all physicians.  In further hardball and last minute negotiations an alternative system named MACRA emerged. 

Both MACRA and MIPS are complex algorithms which are difficult to decipher. They are also based on unproven metrics, which the American College of Physicians and the American Academy of Orthopedic Surgeons is now challenging.

As reported in Healio

In Medicare’s Merit-based Incentive Payment System or MIPS, most ambulatory internal medicine quality measures are not compliant with ACP criteria, according to ACP in a paper published in the New England Journal of Medicine.
“ACP has long supported and advocated improving performance measures so they help physicians provide the best possible care to their patients without creating unintended adverse consequences,” Jack Ende, MD, president of ACP, said in a press release.
To address physicians’ concerns that current performance measures do not meaningfully improve patient outcomes, ACP conducted an analysis of 86 measures in Medicare’s MIPS and Quality Payment Program. The analysis revealed that 37% of the performance measures were valid, 35% were not valid and 28% were of uncertain validity. A majority of measures that were not valid had insufficient supportive evidence.
Some performance measures included poor specifications that could potentially lead to the misclassification of high-quality care as low-quality care, according to the ACP. Measures containing flaws frustrate physicians and may be harmful to patients, ACP noted.
Performance reports cost physician practices $15.4 billion per year, yet almost two-thirds of physicians report that the quality of care that they provide is not adequately captured by current performance measures, according to ACP.
Leading organizations in the United States showed “troubling inconsistencies” in how they rate the validity of physician quality measures, according to ACP.
The ACP recommended that a set of standards for the evaluation of the trustworthiness of performance measures be developed. Performance measurement should not be an isolated drill and not be limited by administrative data, according to ACP.
“A possible solution is to have physicians with expertise in clinical medicine and research develop measures using a clinically relevant methodology,” Ende said. “Performance measures should be fully integrated into care delivery so they can help to address the most pressing performance gaps and direct quality improvement.”
Noting that more than 2,500 measures are used inconsistently, ACP urged for a “time out” to review and improve how physician performance is being assessed. – by Alaina Tedesco
Another ill-defined term which has been used frequently by payers (Medicare et al) is EVIDENCE-BASED MEDICINE.  A problem arises since there are many treatments for conditions where there are no valid metrics for defining what treatments are successful. 
Health Catalyst created an enterprise data solution which merged meta-data with clinician input.  

The basis for many of CMS algorithms are based upon this one company's statements. The difficulty with this is that it was not peer reviewed, nor subject to scientific scrutiny.

The entire validity of alternative payment methodology (APM) rests on their numbers.

Now early studies and statements by credible physicians groups such as the ACP cast doubt on what we call Evidence Based Medicine.

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