The Medicare Payment Advisory Commission has formally recommended to Congress that it repeal the Merit-based Incentive Payment System track of Medicare’s Quality Payment Program.

MedPAC “has concluded that … the Merit-based Incentive Payment System (MIPS) will not fulfill its goals and therefore should be eliminated,” the commission said in its March 15 report to Congress. MedPAC added that the “basic design of MIPS is fundamentally incompatible with the goals of a beneficiary-focused approach to quality measurement.”

The commission notes that the design of MIPS measures quality and adjusts payments based on measures chosen by the individual physician. “But a system built on this design will be inequitable, because clinicians will be evaluated and compared on dissimilar measures. In addition, many clinicians will not be evaluated at all because, as individuals, they will not have a sufficient number of cases for statistically reliable scores.”

MedPAC adds that, by the Centers for Medicare & Medicaid Services’ own estimates, more than half of clinicians will be exempt from reporting on MIPS, based on the low-volume threshold that exempts providers who bill for $90,000 or less in Medicare claims or see 200 or fewer Medicare patients.

The advisory panel also highlighted other flaws. Those include MIPS’ onerous reporting burden; measures that do not allow for meaningful comparisons among clinicians; differing rules for clinicians depending on location, practice size, and other factors; and payment adjustments that could vary wildly from year to year, creating financial uncertainty for physicians.

The commission, which voted 14-2 in favor of eliminating MIPS, also recommended it be replaced with a “voluntary value program.” But it has offered Congress only a conceptual direction for that replacement program.

“This voluntary value program (VVP) is based on the premise that patient outcomes rely on the combined contributions of clinicians and emphasizes that quality improvement is a collective effort,” according to the report.

The VVP would measure all clinicians based on the same set of measures: clinical quality, patient experience, and value. And it would do so on a population level, rather than the individual patient level.

MedPAC sees the VVP not as an end goal in the transition to paying for value, but rather a stepping stone to get clinicians more comfortable with value-based payments en route to moving into the QPP ’s advanced alternative payment model (A-APM) track.

“A VVP’s penalties and rewards might not be significant enough to meaningfully change clinician behavior,” the report stated. “However, the intent is to get clinicians comfortable with being measured in a manner similar to the way they would be in A-APMs. With that experience, clinicians would be poised to form or join robust A-APMs, under which the risk and reward are more meaningful, and the potential for true delivery system reform is within reach.”

There was a near unanimous consensus among MedPAC commissioners that MIPS is flawed, but not all commissioners were ready to give up on it – especially considering how much clinicians have already invested in the program.

MedPAC also heard from the American Medical Association, which voiced opposition to the idea of ending MIPS. In addition, the commission received written feedback from physicians against its proposal.

Other experts support preserving MIPS. Gail R. Wilensky, PhD , economist and senior fellow at Project Hope and a former top health aide to President George H.W. Bush, wrote in the New England Journal of Medicine that MIPS should be fixed rather than scrapped.


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