[Reposted: Joshua M. Liao and Amol S. Navathe. Implications Of MIPS Scoring On Clinician Engagement In Value-Based Payments, Health Affairs Blog, October 30, 2018. https://www.healthaffairs.org/do/10.1377/hblog20181029.492700/full/: Copyright ©2018 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.]

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In a recent post, we described nuances in MIPS scoring that can ultimately lead to discrepancies between frequently referenced (e.g., ±4% in 2017 and ±5% in 2018) and actual professional fee reimbursement adjustments. 

Several implications arise from this approach. First, providers face substantial uncertainty about payment adjustments in the MIPS track. This uncertainty arises from multiple aspects of scoring calculations: (1) Medicare’s use of linear scales and scaling factors that incorporate the performance of others into clinicians’ individual adjustments, (2) the dependence on composite performance score (CPS) for determining payment adjustments, and (3) exceptional performance thresholds that Medicare can update each year. For example, the CPS threshold was increased from 3 in 2017 to 15 in 2018, but the 2019 threshold remains unknown (proposed rules include a potential threshold of 30). Medicare can also adjust rules for each of the MIPS domains that contribute to the CPS.

A related implication is that participation decisions may depend substantially on providers’ beliefs about where they will fall in the range of potential MIPS payment adjustments. For example, providers may find the guaranteed 5% professional fee bonus in the AAPM track more appealing compared to generally publicized MIPS adjustments (e.g., between -4% and +4% in 2017). However, providers might arrive at different conclusions if they perceive their potential adjustments in MIPS to be closer to the upper end of the range, (e.g., a +20-22% upward adjustment in 2017).

Third, clinicians are unlikely to see large positive adjustments, if any, due to the approach Medicare has adopted thus far in MIPS. In 2017, Medicare set the CPS threshold so low that 91% of providers met or exceeded it. Therefore, while Medicare has not yet released information about final CPS distributions and adjustments, a majority of clinicians stand to earn positive adjustments, minimizing the amount per high performer. Similarly, there are likely to be large numbers of exceptional performers (74% of all eligible clinicians in 2018 by Medicare’s estimate) and in turn relatively small bonuses. In sum, actual positive adjustments are likely to fall well short of maximum potential amounts.

Future Directions

For many clinicians, the issues above could add to concerns from policy experts and physicians about MIPS and complicate decisions about how to participate in Medicare’s Quality Payment Program (QPP). In particular, inaccurate perceptions of financial upsides or downsides in MIPS could lead to suboptimal decisions that ultimately slow engagement in value-based payments. Additional uncertainty — for example, through the authority granted Medicare via the recent Bipartisan Budget Act (BBA) of 2018 to delay increases in CPS to the national mean or median (originally planned by 2019, now able to be delayed until 2022) — compounds existing uncertainty. 

Several policy modifications could help. First, Medicare could raise the CPS and exceptional performance thresholds for most clinicians more quickly at a pace aligned with original MACRA legislation. While the slower transition enabled by the BBA of 2018 has been popular with some physician groups, more gradual changes also create the problems of (1) lumping truly exceptional performers in with others and (2) making the upper range of potential positive adjustments far less attainable. Given 91% participation in year 1 of MIPS and projections by Medicare that 74% of clinicians will achieve exceptional performer status in year 2, these two problems are likely to loom large.  

Beyond increasing performance incentives for MIPS clinicians and recognizing truly outstanding performers, raising thresholds would also redistribute the number of low and high performers, preventing a smaller number of the latter from bearing the brunt of large negative adjustments. Therefore, with the right protections in place for certain clinicians (e.g., those in safety-net organizations), a more rapid ramp up is consistent with the overall goal of shifting towards value-based payments.

Second, Medicare could accelerate cost accountability for MIPS clinicians by increasing the cost domain weight more rapidly and continuing to introduce episode-based cost measures to complement global measures such as total per capita costs. While the desire to ease clinicians into MIPS is laudable, physicians may be more ready to assume greater degrees of cost accountability than predicted.  Such changes would also better align cost incentives between MIPS and AAPMs, as Medicare is doing for other domains such as promoting interoperability (e.g., both MIPS and AAPMs require will clinicians to use 2015 certified electronic health record technology). Focusing on episode-based measures in particular would expand the salience and accountability of the cost domain beyond primary care to a broader range of subspecialist clinicians.

As MIPS moves towards meaningful incentives to shift care towards value, Medicare must be mindful of equity and potential unintended consequences to different clinicians, particularly those who care for high need and low-income populations. For example, although the broad goal of moving towards value via alternative payment models may be appropriate for most clinicians, the significant limitations in social risk adjustment (e.g., only dual eligibility status considered), mean that additional protection may be needed for those who care for high proportions of socioeconomically or otherwise vulnerable patients. Medicare should also monitor any unintended consequences of MIPS policy on smaller practices.

Final Thoughts

Potential discrepancies between broadly publicized and actual MIPS payment adjustments could hamper clinicians’ ability to select the most appropriate QPP track and inadvertently undercut Medicare’s efforts to incentivize providers to shift towards value. The several changes outlined in this post could address both issues.