WASHINGTON (FRONTLINE MEDICAL NEWS) – The Medicare Payment Advisory Commission continues to mull the specifics of its proposed recommendation to scrap the Quality Payment Program’s MIPS component.

The basics of the MIPS (Merit-based Incentive Payment System) replacement have not changed. The proposal calls for creation of a voluntary value program (VVP) that would withhold a percentage – currently 2% – of Medicare payments for physicians who are not part of an advanced alternative payment model ( APM ) under the Quality Payment Program of the Medicare Access and CHIP Reauthorization Act of 2015.

There would be two ways to recapture the withheld pay. The first would be to join an APM. The second would be to participate in a VVP by entering a voluntary reporting group. Under the proposal, VVPs would be at least 10 providers who would report together on population-based measures, patient experience, and cost measures, according to staff presentations given Nov. 2 at a meeting of the Medicare Payment Advisory Commission (MedPAC).

Proposed measures would be patient oriented, would encourage coordination across all providers, would promote positive change in the delivery system, and would be less burdensome to providers. Measures would be more in line with those employed by APMs – important because the overall goal would be encouraging participation in an APM rather than permanently lingering in the VVP.

To that end, MedPAC staff member Kate Bloniarz noted during the presentation of the VVP proposal that the total payments in the program “should be capped to be less attractive than joining an [advanced] APM. This comes from a general sense among commissioners that clinicians should not be able to receive large bonuses” for remaining in Medicare fee-for-service.

MedPAC staff recommended that the Centers for Medicare & Medicaid Services offer a fallback group that would provide an option to providers that would otherwise not have access to other groups to join.

Commission member Kathy Buto, former vice president of global health policy at Johnson & Johnson, suggested withholding be increased to perhaps 3%, with providers able to recoup 2% in the VVP and 3% in an APM, to further incentivize APM participation.

Staff noted that certain quality measures and process measures would be lost if MIPS were to go away, but they could be accounted for in other channels, such as through electronic health records and registries.

Most commissioners expressed support for both the repeal of MIPS and the conceptual framework for the new VVP, although many sought more details, particularly in the handling of specialists.

“I don’t know that we want to try to make the VVP do too much, especially when you get into the specialties that are very, very episodic,” said commission member Brian DeBusk, PhD, CEO of DeRoyal Industries. “The classic example would be a joint replacement. … I hope to see some specialist APMs developed in parallel and I think that is going to take some pressure off to try to make the VVP be all things to all people.”

Commission member Pat Wang, CEO of Healthfirst, offered a possible solution.

“I would suggest that we try to think about doing that in the context of something that is a little bit, perhaps, not full bore APM, but a VVP for specialists with their own metrics that are not big, gigantic readmissions,” she said. “Those are very broad population health metrics [that may not work for specialists].”

But at least two commission members voiced their dissent to the proposal as presented, with one going so far as to saying that MIPS should not be repealed.

David Nerenz, PhD, of the Henry Ford Health System, said that he had “very serious concerns about the VVP part of this proposal [and] they are such that if it comes to us as a recommendation in more or less its current form I will not support it.”

He called it “pretty significant social engineering in the structure of medical practice and I think we are doing it in the absence of what to me would be compelling evidence that this large group structure we are talking about is good.

“I also don’t see any evidence that beneficiaries find value in the set of measures we are talking about,” Dr. Nerenz added. He is on the record as supporting the repeal of MIPS.

Commission member Alice Coombs, MD, of Weymouth, Mass., was the lone voice speaking in support of MIPS: “I think MIPS has a lot of problems … but there are some things that are coming out of MIPS that are actually good.”

She called the VVP proposal “inadequate” and took issue with the measures. As a practicing physician, she said that she favors more population health measures that will affect patient outcomes.

MedPAC staff expect to have a draft recommendation prepared for discussion at the December meeting, with a final vote on what will be presented to Congress coming as soon as January.