A new government watchdog report offers more doubt about the effectiveness of a heavily criticized Medicare provider payment program.
The Merit-based Incentive Payment System scores physicians and other providers based on quality and cost measures and uses those scores to adjust future Medicare payments. Congress and President Barack Obama established MIPS in a 2015 law intended to improve outcomes and reduce spending.
MIPS lets providers cherry-pick the measures they report and doesn't yield enough of a payoff to be worth participating in, said most stakeholders the Government Accountability Office interviewed for an analysis published Friday.
"There is relatively modest upside to the bonuses that MIPS provides medical practices," said Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association. In a 2019 survey, 94% of MGMA members said MIPS was moderately to extremely burdensome.
Although the GAO report also generated some positive feedback, the list of complaints was much longer. These grievances aren't new; provider groups have condemned the program for years. The Medicare Payment Advisory Commission has called for MIPS to be scrapped. The Centers for Medicare and Medicaid Services did not respond to a request for comment on the GAO report and provided only technical comments to the investigative agency.
The GAO's findings echo what MGMA members tell the association, Gilberg said. "It just becomes kind of a frustrating, bureaucratic exercise in the minds of a lot of medical groups," he said.
The GAO interviewed 11 stakeholder groups that represent MIPS-eligible providers, which include physicians, nurse practitioners, physical therapists and others. The program is mandatory unless providers qualify for an exemption, such as having $90,000 or less in annual charges under Medicare Part B.
On the bright side, stakeholders told the GAO that the program's bonuses for small practices and those with complex patients help providers that otherwise would be disadvantaged. They also praised the minimum participation threshold because it exempts smaller providers that wouldn't benefit from MIPS.
Stakeholders also like that MIPS exempts providers from performance categories that aren't relevant to their practices. Radiologists and pathologists don't have to report on promoting interoperability, for example.
The overwhelming majority of providers that participate in MIPS earn money as opposed to being penalized. Of the 1 million clinicians who participated in MIPS' first year in 2017, 93% received bonuses starting in 2019. Roughly 5% received a penalty as high as 4%.
But a common complaint is that those financial rewards are too small. The largest Medicare payment adjustment was about 1.9% between 2017 and 2019. Eight out of the 11 stakeholder groups told the GAO that the positive adjustments didn't cover the administrative cost of complying with the program.
The GAO report includes the hypothetical example of a well-performing practice with $100,000 in Part B payments that received less than $2,000 in enhanced payments, yet spent $10,000 to get MIPS-specific reports from its electronic health records vendor to participate.
In another example, a provider with $90,000 in Medicare payments would only see an extra $1,692 in payment year 2019 even with the maximum positive adjustment of 1.9% based on performance year 2017.
That low return probably means some providers will opt not to report to MIPS and will instead accept payment penalties, the GAO wrote. CMS has said performance year 2022 might yield greater returns on investment and higher payment adjustments.
Eight of the 11 stakeholder groups also questioned whether MIPS helps with quality or patient outcomes. Providers can maximize their upward adjustments by picking performance measures they're doing well on and ignoring those on which they performed poorly, they told the GAO.
Stakeholders also warned the GAO that providers might perform unnecessary screenings to meet quality measures. For example, a physical therapist could evaluate all diabetic patients for proper footwear, even if they came in to have their fingers evaluated.
MIPS evaluates four categories of outcomes. To show quality, providers submit data for at least six measures, with a variety of possible metrics from which to choose. On the cost front, CMS uses Medicare Part A and Part B claims to calculate providers' performance. Providers must prove they engaged in performance improvement activities, like antibiotic stewardship classes. They also must demonstrate that their electronic health records meet program standards.
MIPS was originally introduced as part of a broader physician payment law called the Medicare Access and CHIP Reauthorization Act, or MACRA. The payment initiative was designed to be a transitional program for providers that weren't already involved in more clinically relevant quality improvement programs, Gilberg said. However, many providers feel stuck in MIPS in the absence of widely used alternative payment model options, he said.