MIPS Value Pathways: A Salient Development for Internists

During the past 3 years, the Centers for Medicare & Medicaid Services (CMS) has used its Merit-based Incentive Payment System (MIPS) as a key payment reform strategy to lead the nationwide shift toward value-based payment and care. As highlighted in an Annals editorial published shortly after implementation in January 2017 (1), MIPS is designed as a pay-for-performance program—the largest of its kind to date—that holds clinicians who care for Medicare beneficiaries financially accountable for the quality and cost of care. It does so by measuring clinician performance on 4 domains of care—quality, improvement activities, cost, and promoting interoperability—and using that performance to increase or decrease clinicians’ professional payments.

However, as noted in an Annals Ideas and Opinions article, MIPS has potential problems that underscore the need for policy strategies that “encourage the continued growth of…alternative payment models” (2). These models are so named because they represent distinct departures from volume-based, fee-for-service models, and clinicians participating in them are exempt from MIPS. Like MIPS, alternative payment models are designed to financially incentivize the delivery of high-value care. Prominent examples include accountable care organizations and bundled payments.

One strategy for encouraging alternative payment model participation is the development of clinical specialty–oriented MIPS “value pathways.” Although more information is needed, CMS seeks to begin implementing value pathways for different specialties in 2020 to change how clinicians engage with MIPS and align the program more closely with alternative payment models. Key principles articulated by CMS in designing value pathways include the desire to increase the salience of MIPS to clinicians in different specialties while reducing reporting burden. For instance, surgeons participating in MIPS could report on a smaller set of quality measures that emphasize operative and postoperative outcomes, rather than a larger number of general, nonsurgical measures that may be more pertinent to nonsurgeons.

For specialties like internal medicine, the success of MIPS value pathways will rest on their design and implementation. Internal medicine is an inherently broad specialty that emphasizes care coordination across conditions and procedures—a feature that could complicate efforts to create a standardized pathway that reflects a given clinician’s activities. In particular, in contrast to clinicians in other specialties, internists care for a wide range of conditions using a broad set of diagnostic and therapeutic interventions.

Nonetheless, if implemented well, value pathways could help improve internists’ experiences with and engagement in MIPS. By moving away from the existing MIPS participation approach, value pathways could also reduce existing criticism levied on the program by practicing physicians and policy groups, such as the Medicare Payment Advisory Commission, which includes concerns about the program’s effectiveness, clinical salience, high reporting burden, and potential for creating unintended consequences. Given these stakes, MIPS value pathways are an important policy development for internal medicine clinicians and group practices to be aware of and monitor.

References

1. Nuckols TK. With the merit-based incentive payment system, pay for performance is now national policy. Ann Intern Med. 2017;166:368-9. [PMID: 28114662] doi:10.7326/M16-2947
2. McWilliams JM. MACRA: big fix or big problem? Ann Intern Med. 2017;167:122-4. [PMID: 28505630] doi:10.7326/M17-0230