Over the past two years or so, the Centers for Medicare and Medicaid Services (CMS) has placed increasing importance on a program they’re in the process of developing which is collectively called MIPS Value Pathways, or MVPs. MVPs are seen by some as the next step in the process of incentivizing physicians and everyone else in medicine to move away from the Merit-based Incentive Payment System (MIPS) as their value-based payment model of choice, and instead begin taking on risk as part of any one of a number of advanced alternative payment models.
So what is MIPS, what are value pathways, and what the heck does any of this have to do with population health?
Let me explain it as I see it.
What is MIPS?
There have been a couple of iterations of MIPS so far, but the most concise definition I’ve seen was put forward by the American Academy of Physical Medicine and Rehabilitation:
The Merit-Based Incentive Payment System (MIPS) is the program that will determine Medicare payment adjustments. Using a composite performance score, eligible clinicians (ECs) may receive a payment bonus, a payment penalty or no payment adjustment.Source: https://www.aapmr.org/quality-practice/quality-reporting/merit-incentive-payment-system
MIPS is one of two tracks set up under something called the Quality Payment Program (QPP) by CMS, the other track being something called Advanced Alternative Payment Models (APMs). I won’t spend much time on APMs in this post, but they’re basically the future of physician reimbursement and probably deserve a post of their own.
Anyway, under MIPS, participating physicians, groups, or health systems report the measures and activities they collect during a performance period within four different performance categories: Quality, Improvement Activities, Promoting Interoperability, and Cost.
I won’t go into the myriad activities that count toward attesting to these requirements, but suffice it to say that participants earn a composite score in these four domains and, as the AAPM&R website says, “Your final score determines the payment adjustment applied to your Medicare Part B claims.”
Put simply: if you outperform the overall measurement expectation, you’ll earn a positive pay adjustment and receive a bonus. If, on the other hand, you underperform on the metrics, you’ll get a negative payment adjustment. On the bright side, CMS collects and calculates all cost measures, so at least that burden doesn’t fall on the physician.
This formulation is at the heart of risk-sharing as conceived by CMS. The point of all this is to rein in out-of-control medical spending while improving the patient experience. I’ve left out plenty of other details about MIPS, such as the fact that not every physician fits into the MIPS framework and are thus exempt from participating, but you get the general idea.
What are MVPs?
I’m glad you asked, because I’m still trying to figure this one out myself. For the most part, MVPs seem like an attempt by CMS to overhaul the MIPS process because they got a lot of negative feedback from the medical establishment that participation was too challenging.
So through MVPs, CMS is attempting to streamline the reporting process while at the same time empowering patients to take on more of an active role in their care. And in another encouraging sign, CMS is actively soliciting ideas for MVPs from the field.
According to a 2019 article in Health Affairs, CMS has put forward several guiding principles which it hopes will resonate with the house of medicine. According to the article:
…value pathway design should reduce barriers to provider participation in alternative payment models (APMs) by prioritizing quality measures that align with improvement activities and cost measures. CMS proposes holding clinicians from all specialties accountable for a foundational set of health information technology and population health measures, while allowing quality, improvement activity, and cost measures to vary by clinical specialty. Creating common measures to assess performance in fee-for-service (via MIPS) and APMs may facilitate the transition to APMs.Source: https://www.healthaffairs.org/do/10.1377/hblog20191107.686469/full/
To put a finer point on it, here is how CMS explains this new approach:
The MVPs framework aims to align and connect measures and activities across the quality, cost, and improvement activities performance categories of MIPS for different specialties or conditions. In addition, the MVPs framework incorporates a foundation that leverages Promoting Interoperability measures and a set of administrative claims-based quality measures that focus on population health/public health priorities and reduce reporting.
Implementing the MVP framework honors our commitment to keeping the patient at the center of our work. In addition to achieving better health outcomes and lowering costs for patients, we anticipate that these MVPs will result in comparable performance data that helps patients make more informed healthcare decisions.Source: https://qpp.cms.gov/mips/mips-value-pathways
So not only is patient empowerment at the heart of this program, but these measures will “focus on population health/public health priorities.”
What Role Does Population Health Play in MVPs?
This is the part I’m foggiest about. Part of the reason for my confusion is that CMS is still developing this concept, so it’s only natural that there would be gaps in the public’s understanding of it. Speaking of gaps, in 2020 CMS commissioned something called an “MDP Population Health Environmental Scan and Gap Analysis Report.” As stated above, one major goal of this report — and of MVPs in general — was to bring about “a future state of MIPS that CMS envisions to include a foundation of measures focused on population health.”1
But when CMS highlights “population health” as important to their program, it’s not entirely clear to me what they mean by “population.” I previously covered the flexibility of this term, so for more on that, check out this blog post.
In other words, are they taking an inclusive perspective, where “population” can mean everything from designing metrics around patient populations in clinical settings to those predicated on geographic pools of potential patients, such as a county with higher-than-average smoking rates? Or do they have a narrower definition in mind?
According to the report, “The scan was organized by six topics of population health: access, clinical outcomes, coordination of care and community services, health behaviors, preventive care and screening, and utilization of health services.” To me, this signals that CMS is applying a more inclusive definition of “population” beyond just the clinical setting. And they seem to be really keying in on underserved populations in both urban and rural settings. Much remains to be seen, though, so stay tuned.
- CMS Quality Measure Development Plan. “2020 Population Health Environmental Scan and Gap Analysis Report For the Quality Payment Program.” Page 1. Accessed on 12/1/21