An Opportunity for Internists to Lead in Value-Based Care Through MIPS Value Pathways

In a recent Fresh Look post, we discussed the salience of emerging specialty-focused “value pathways” in the Merit-based Incentive Payment System (MIPS) to internists. Pathways designed to reflect the work and scope of specific clinical specialties could help overcome problems with MIPS, such as issues raised by policy experts writing in Annals (1), and improve clinicians’ experiences with and engagement in the program.

However, pathway implementation may be particularly challenging for specialties like internal medicine. Internal medicine is inherently broad, with emphasis on many different clinical areas along with care coordination across different conditions and procedures with clinicians in other specialties. This breadth is reflected in the wide range of clinical capacities filled by internists across outpatient (for example, primary care clinicians), inpatient (for example, hospitalists and consultative medicine), and postacute care settings (for example, “SNFists” who care for patients in postacute care facilities). However, this breadth also complicates a key goal of MIPS value pathways—establishing a single group of measures to capture the work done by clinicians in a given specialty.

One way to avoid these issues would be to consider an internal medicine pathway focused on value-based care delivery rather than clinical decisions. Internists have a long-standing reputation as local and national leaders in quality improvement, patient safety, and other areas highly related to health care value. Internal medicine has also long been a focus area for payment models (for example, capitation and new direct contracting models) and delivery reforms (for example, patient-centered medical homes) aimed at improving value.

In addition, many measures already used in MIPS could be used in new value-based care delivery pathways. For instance, ensuring documentation of current medications and advanced care planning are value-focused measures with wide, crosscutting applicability to the work of many internists. Among improvement activities, those focused on the use of decision support and standardized treatment protocols also fit that bill. Consequently, a value pathway composed of measures and activities emphasizing high-value care delivery processes could feature these strengths and increase the salience of MIPS as a value-based program to many internists. For instance, a value-based MIPS pathway could be salient for hospital- or inpatient-based internists (see figure below). Such pathways would also address an underlying goal of value pathways—to better align participation in MIPS and alternative payment models and encourage more participation in the latter over time.

To both overcome the potential mismatch between the focused nature of MIPS value pathways and the broad scope of internal medicine as well as to capitalize on value pathways as an opportunity to continue leading in clinical and value-based care delivery, policymakers and internists could work together to explore an internal medicine value-based care delivery pathway. Doing so alongside other MIPS participation could help better engage internists in MIPS and value-based delivery reform.

References

1. McWilliams JM. MACRA: big fix or big problem? Ann Intern Med. 2017;167:122-4. [PMID: 28505630] doi:10.7326/M17-0230