The Authorities Accountability Workplace (GAO) final week revealed a report evaluating the Advantage-based
Incentive Fee System (MIPS). MIPS is an strategy for CMS to pay physicians caring for Medicare beneficiaries primarily based not simply on quantity however on worth. MIPS evaluates supplier worth alongside 4 dimensions: (1) high quality, (2) enchancment actions, (3) selling interoperability, and (4) price. Beneath I summarize the report together with background on the MIPS program, the outcomes of the GAO analysis of MIPS scores and bonus funds, and abstract of stakeholder suggestions.


  • Exemptions. Some suppliers may be exempt from MIPS, usually if they’ve smaller practices. That is for 2 causes: first the burden of MIPS reporting is extra burdensome to small suppliers (because of economies of scale) and since smaller pattern sizes imply that high quality measures are much less dependable. Physicians may be exempt from MIPS if they don’t meet all the following Three standards: (i) billed greater than $90,000 for Half B companies (ii) seen greater than 200 Half B sufferers, and (iii) rendered greater than 200 coated skilled companies to Half B sufferers.
  • People vs. teams. Physicians can take part in MIPS both as particular person physicians or as a gaggle follow. The unit of statement for the group follow is the Tax Identification Quantity or TIN. Since 2018, particular person physicians may take part as “digital teams” in the event that they wish to pool their scores, however function as separate TINs. This will increase the pattern sizes and makes high quality measures much less unstable on a year-to-year foundation.
  • Different Fee Fashions. Some physicians additionally take part in various cost fashions (APM) such because the Medicare Shared Financial savings Program (MSSP). Suppliers which are a part of an APM entity could also be collectively scored as an APM entity group and cost changes could happen primarily based on the APM guidelines.
  • Efficiency Scores
    • High quality measures. Physicians are required to pick at the very least 6 high quality measures associated to the care they offered to their sufferers through the 12 months. Some high quality measures are chosen from pre-determined specialty checklist, however physicians get to decide on the 6 measures over which they’re evaluated.
    • Enchancment actions. These are actions the practices should have interaction in to enhance the follow. Examples embody finishing CDC’s antibiotic stewardship course.
    • Interoperability. This requirement pertains to promiting affected person engagement and insuring that digital well being data are licensed and that the physicians programs are able to e-prescribing.
    • Price. Price is calculated primarily based on the overall price of take care of all the doctor’s attributed sufferers primarily based on Medicare Half A and B claims.
    • Bonus factors. Suppliers can get bonus factors if they’ve “complicated” sufferers primarily based on the share of sufferers who’re twin eligible and there’s a “small follow bonus” for practices with 15 or fewer suppliers who submit at the very least 1 high quality measure.
  • Funds. Practices with larger scores get bonus funds and people with decrease scores obtain penalties. The funds are set in a finances impartial trend in order that (exterior of the prices for CMS to manage the MIPS program) there isn’t a internet impression of those funds on the CMS finances. The utmost damaging cost is -9%; the utmost optimistic cost is ready to make sure that this system stays finances impartial in a given 12 months. In 2021, the vary was -9% to +9%.


How did Medicare physicians fare on the MIPS program? GAO writes:

… MIPS ultimate scores have been usually excessive from 2017 via 2019, with most MIPS-eligible suppliers qualifying for a optimistic cost adjustment. Throughout the three years, median ultimate scores ranged from about 89.7 to 99.6 (out of a attainable 100)—effectively above the efficiency threshold (see fig. 2).26 Not less than 93 p.c of suppliers certified for a optimistic cost adjustment in any 12 months, and not more than 4.eight p.c of suppliers certified for a damaging cost adjustment…

The utmost optimistic cost adjustment for any of efficiency years 2017 via 2019 resulted in comparatively small will increase in Medicare funds. For instance, a supplier with $90,000 in Medicare Doctor Payment Schedule funds would solely see a rise of $1,692 in cost 12 months 2019 in the event that they obtained the utmost optimistic adjustment of 1.88 p.c primarily based on their efficiency in 2017.


Unsurprisingly, supplier teams welcomed extra flexibility. For example, some supplier teams obtained exemptions from reporting alongside sure dimensions (e.g., radiologists and pathologists didn’t must report “selling interoperability”). Smaller supplier teams additionally appreciated the “small follow bonus” and the low quantity threshold which exempted the smallest suppliers from MIPS participation.

Key critiques embody: that suggestions was not well timed or significant to many suppliers.

  • Suggestions shouldn’t be well timed. Suppliers must submit prior 12 months knowledge by the tip of March after which suppliers don’t get suggestions from the CMS evaluation till July. From the supplier perspective, that is already greater than 6 months into the subsequent 12 months. From CMS’s perspective, dashing up the information submission deadlines is prone to obtain pushback from suppliers in regards to the undue burden of information submission.
  • Suggestions shouldn’t be significant. Practices are extra occupied with their efficiency relative to their friends in the identical specialty and geographic areas and requested CMS to supply these statistics. Additionally, many suppliers–particularly bigger practices–could also be selecting high quality measures strategically to maximise their funds. A variety of stakeholders additionally famous that the measures of curiosity weren’t very clinically significant. Many consider that MIPS results in suppliers prioritizing reporting over high quality of care, since it’s (financially) higher to decide on metrics the place the follow is already performing effectively reasonably than ones the place the follow would wish to enhance.
  • Robustness of metrics. Some metrics don’t occur ceaselessly sufficient to be exactly measured. CMS faces the problem that the extra particular the measure is, the extra related it will likely be to sure physicians; nonetheless, the extra particular the measure turns into, the smaller pattern measurement and fewer sturdy high quality metric turns into.
  • ROI. Apply return on funding from MIPS participation was low. The cost bonuses have been pretty low, however the administrative burden and value to the follow was pretty excessive.


To deal with some challenges, CMS’s 2022 proposed rule plans to implement the MIPS Worth Pathway (MVP) in efficiency 12 months 2023.

If the rule is finalized as proposed, MVPs will enable suppliers the choice of reporting on a gaggle of actions and measures from the 4 MIPS efficiency classes which are related to a particular specialty, medical situation, or episode of care.39 Below the proposal, in 2023, suppliers could register to report knowledge and obtain suggestions on considered one of seven MVPs associated to the next scientific subjects: (1) anesthesia, (2) persistent illness administration, (3) emergency drugs, (4) coronary heart illness, (5) decrease extremity joint restore, (6) rheumatology, and (7) stroke

As well as, CMS proposes to permit subgroup reporting for MVPs..[which] would enable a specialty inside a big multi-specialty group to register as a subgroup and obtain extra clinically significant suggestions on its measures and actions within the high quality, enchancment actions, and value efficiency classes.

The MVP framework would additionally standardize efficiency measurement throughout chosen specialties, medical situations, or episodes of care. A extra cohesive set of measures will help cut back the quantity of “gaming” the system that suppliers can do.


Please enter your comment!
Please enter your name here