Written by Jason Lesnick
The Medicare Merit-based Incentive Payment System (MIPS) seems to be ineffective at measuring quality of care and incentivizing quality improvement.
Why does this matter?
We may not be primary care physicians, but MIPS is the largest value based payment program in the US and influences reimbursement for hundreds of thousands of physicians. If our quality measuring systems aren’t working, we need to re-examine them and seek alternatives.
Here’s a quip: What isn’t wrong with MIPS?
This 2019 cross sectional study of 80,246 US primary care physicians and 3.4 million patients, which evaluated associations between MIPS scores and performance on 5 unadjusted process measures, 6 adjusted outcome measures, and a composite outcome measure.
4,773 physicians had low MIPS scores, 6,151 had medium scores, and 69,332 had high scores. 2019 was the program’s third year, and 99% of eligible clinicians participated.
Compared to physicians with high MIPS, those with low MIPS:
- Had visits with more unique enrolled patients
- Were more likely to work in a smaller practice
- Were less likely to practice in multi-specialty groups or be affiliated with a health system
- Cared for patients more likely to be Medicare and Medicaid eligible, Hispanic, and/or medically complex
- Had lower rates of diabetic eye exams, HbA1c screenings, and mammography screening
- Had higher rates of influenza vaccinations and tobacco screenings.
Compared with patients of physicians with high MIPS scores, patients of physicians with low MIPS scores:
- had higher rates of hospitalization
- had significantly lower rates of ED visits
19% of low MIPS physicians had a composite clinical outcome score in the top quintile of all primary care physicians (compared to 19.8% with high MIPS scores). Among physicians with high MIPS scores, 20.5% had a composite clinical outcome score in the bottom quintile (compared to 15.1% of physicians with low MIPS scores).
Alarmingly, physicians with low MIPS scores who performed in the top quintile were more likely to care for Medicare and Medicaid eligible patients, Black patients, Hispanic patients, and medically complex patients. Meanwhile, physicians with high MIPS scores and bottom quintile clinical composite outcomes cared for fewer patients, were more likely to work in larger groups, less likely to practice in a rural area, less likely to care for Medicare and Medicaid eligible patients, Black patients, and medically complex patients.
The authors hit the nail on the head with this: “The level of discordance between physician MIPS scores and performance on patient outcomes suggests that MIPS 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.”
I would take it one step further – MIPS may be penalizing those delivering high quality care to vulnerable populations. This study also supports the concerns that MIPS doesn’t accurately measure quality of care but instead the ability of organizations to report data.
Value based healthcare is all the rage and is likely to continue to be emphasized in the future. We need to ensure these systems are functioning as intended and hold them accountable as these authors have done.
Association Between Individual Primary Care Physician Merit-based Incentive Payment System Score and Measures of Process and Patient Outcomes. JAMA, 328(21), 2136–2146. https://doi.org/10.1001/jama.2022.20619