December, 2016

MIPS and Drabs

By Michael J. Katin, MD

Last month all attention was directed to an event in the United States whose outcome would unquestionably affect all citizens with ramifications that could extend globally. This was the November 17 meeting in Tampa, Florida, of the Technical Expert Panel of the CMS Quality Measure Development Plan.

In other news from November, Gary Johnson of the Libertarian Party received 4,012,671 votes compared to Jill Stein, MD, of the Green Party, who received 1,192,344 votes. Mr. Johnson's total would have been enough to have won the Presidency in 1872, Electoral College permitting. That was even longer ago, however, than the 108-year gap that ended with the major event of November, if not the entire century .

The Centers for Medicare and Medicaid Services is a government agency which is budgeted for $681,608,700,000.00 for Fiscal Year 2017. This amount of money is equivalent to 21st place in Gross Domestic Product of all the countries in the world, just behind Saudi Arabia.

Despite all this funding, it is not possible for CMS to pay for everything it should. It was therefore thought necessary to change the entire mindset of payment for medical services and, specifically, for physician services, to reflect quality rather than quantity. It's probably a good thing it doesn't run the Agriculture Department or we'd be starving.

Granted, quality is important but it's also necessary to supply services, this will become more obvious when patients are waiting weeks to be seen by physicians who have to take three-quarters of their time filling out irrelevancies on iPad screens before having to leave at the end of their shifts to go to the second jobs they need to support their families.

Interestingly, for the first time the members of a panel to address clinical medical issues contained a majority of MDs (14!) but only one DO, one RN/FNP, and one PA-C out of 22 persons. On further examination, most of the MDs were affiliated with managed care groups, academics, and professional organizations, all of which involve a great deal of knowledge but which call in to question their perspective on practicality.

For the few persons who haven't already heard this summary: for years we were threatened by draconian cuts in the fee schedule due to ill-conceived Sustained Growth Rate (SGR) . This horrendous entity was put to sleep in 2015 and replaced with a more horrendous entity, the Medicare Access and CHIP Reauthorization Act (MACRA) . This beast sought to change the system of payment to depend on either a Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs), now more recently combined as the Quality Payment Program (QPP). As with many things in government, it was then necessary to figure out what was actually meant by these. The CMS Quality Measurement Development Plan then sought to specify what quality measures should be utilized and, as mentioned multiple paragraphs above, the first full meeting of the Technical Expert Panel was convened. Were these people who technically were experts or experts in technique? In fact, the technique was obvious since the report generated a 43-page document (including six appendices) replete with terminology such as domains, measures, linkage, conceptual framework, environmental scan, gap analysis, crosscutting, and, of course, conceptual framework, plus with references to more stakeholders than would be found in the entire province of Transylvania. In the midst of multiple paragraphs of quality metrics is included scattered anecdotal references with little relationship to the final product, including one particularly sad presentation by a caregiver about difficulty with coordination of efforts through the course of a serious illness of a relative, providing the implication that external forces need to seamlessly guide a patient through eligible programs (more of a topic for hospitals or for policies on chronic care than for this meeting). There was also a statement by one of the panel members about her own problems with delayed diagnosis, which would be difficult to prove would have necessarily been any different with all the MIPS and whistles in place. The two most impressive items are the comparison of the top ten pre-assessment topic rankings by patients and caregivers versus the top eleven pre-assessment topic rankings by the Technical Expert Panel. Amazingly, "Outcomes" was item number 6 for patients and caregivers and number 1 for the TEP! In other words: the plane crashed in Utah instead of making it to San Francisco, but the refreshment service was good, there were all new movies to watch, and there was no charge for the first checked luggage item.

Reading the entire document is worth the effort and additional items need not be emphasized, with the exception that under the specialty of Oncology, "Stage-Specific Survival Rates" was originally got a median score of 8.0 on a range of 1 to 9 in importance, and then after discussion dropped to 7.0. It would have been interesting to have heard that discussion.

In any event, we need to admire the time and effort that these 22 persons put into producing this publication, knowing as they did that, as with the delegates who worked to create the United States Constitution, it would be impossible to make everyone satisfied and it is kept in mind that after all the initial efforts and compromises, it took 2 years and 8 months after the United States Constitution was drafted for the 13th state, Rhode Island, to ratify it.

With all due respect, this document will never again be compared to the Constitution.

Emanuel Countdown: Dr. Ezekiel Emanuel's biographies list his birth year as 1957 but, interestingly, do not list a birth date. He has expressed that he does not wish to live past his 75th birthday. Giving him every benefit of the doubt, he will have his 75th birthday no later than December 31, 2032. Including December 1, 2016, this leaves 5,875 days to his goal.