The Medicare Merit-based Incentive Payment System (MIPS) unfairly penalizes physicians caring for a patient population with more complex medical needs, according to a study in JAMA Network.
MIPS, the largest value-based payment system in the U.S., pays about 1 million physicians who care for Medicare patients based on scores in four categories: cost, quality, improvement activities and interoperability.
In a cross-sectional study of 80,246 primary care physicians participating in the MIPS program in 2019 who cared for 4.6 million patients, researchers with Weill Cornell Medical College concluded that “MIPS scores were inconsistently related to performance on process and outcome measures, and physicians caring for more medically complex and socially vulnerable patients were more likely to receive low MIPS scores, even when they delivered relatively high-quality care.”
Corresponding author Amelia Bond, Ph.D., of the Department of Population Health Sciences at Weill Cornell Medical College, told Fierce Healthcare that “while we can only speculate why this might the case, our results suggest that MIPS may be measuring a practice’s ability to collect measures rather than a physician’s performance on measures clinicians and patients truly think are important. Additionally, the MIPS program may not be adequately adjusting scores for physicians who provide care to medically complex and socially vulnerable patients.”
Data were collected from the 2019 Physician Compare files, the Medicare Data on Provider Practice and Specialty (MD-PPAS) file and a 20% sample of 2018-19 Medicare fee-for-service claims.
The study asked: Are physician MIPS scores related to better clinical process measures performance? Are higher MIPS scores related to better patient outcomes? And why do some PCPs have low MIPS scores and good outcomes, and others have high MIPS scores and poor outcomes?
The PCPs were rated on five unadjusted process measures: diabetic eye examination, diabetic HbA1c screening, breast cancer screening, tobacco screening and influenza immunization. They were also scored on six adjusted outcome measures: hospitalizations, emergency department visits, heart failure ambulatory-care sensitive admissions, COPD ambulatory-care sensitive admissions, diabetes ambulatory care-sensitive admissions and hypertension ambulatory-care sensitive admissions.
Of the 80,246 PCPs, 4,773 had low MIPS scores, 6,151 had medium MIPS scores and 69,322 had high MIPS scores. PCPs with low MIPS scores showed significantly lower performance for HbA1c screening, diabetic eye examinations and mammography screening. On the other hand, they performed significantly better on flu vaccination and tobacco screening.
In addition, PCPs performed significantly better on one outcome, emergency department visits, and significantly worse on all-cause hospitalizations per 1,000 patients but did not perform significantly differently on four ambulatory care-sensitive admission outcomes.
“The level of discordance between physician MIPS scores and performance on patient outcomes suggests that the MIPS program is approximately as effective as chance at identifying high vs. low performance: There were an equal proportion of physicians with low MIPS scores in the top quintile of performance and physicians with high MIPS scores in the bottom quintile,” the study found.
Bond said that “concerningly, we do find that the MIPS program may penalize physicians who see more medically complex and socially vulnerable patients even when these physicians have good outcome measures.”
In addition, physicians participating in MIPS pay to play. Researchers citing previous studies note that in 2017, it cost PCPs more than $1.3 billion to comply with MIPS rules. In 2019, physician practices spent more than $12,000 per PCP to participate in the program.
The MIPS program, as currently structured, also has the potential to exacerbate health inequities by transferring resources from physicians caring for less affluent patients to those caring for more affluent patients, the study said.
“Furthermore, financial penalties for poor program performance are scheduled to increase in the coming years; this may impose an undue financial burden on safety-net organizations, given the finding that physicians with low MIPS scores, but strong clinical performance, were more likely to care for socially vulnerable patients," the researchers wrote.
Based on 2019 performance scores, Medicare Part B fee-for-service payments could have been adjusted by plus or minus 7% in 2021, although actual adjustments were smaller, said Bond. “These adjustments go up to [plus or minus] 9% in 2024. All this is to say, these adjustments have the potential to be very large and meaningful to providers.”