Researchers: MDs Treating Socially At-Risk Patients Fared Poorly Under MIPS in 2019

A team of healthcare researchers has found a set of concerning results, coming out of a statistical analysis of caseloads of patients who are socially at risk. Their findings were published in the September issue of Health Affairs. “Clinicians With High Socially At-Risk Caseloads Received Reduced Merit-Based Incentive Payment System Scores” was written by Kenton J. Johnston, Jason M. Hockenberry, Rishi K. Wadhera, and Karen E. Joynt Maddox.

The researchers looked at the first round of performance data from the MIPS (Merit-Based Incentive Payment System) program under Medicare. As the write in the abstract to the article, “To understand how clinicians with high caseloads of socially at-risk patients fare under Medicare’s new outpatient Merit-based Incentive Payment System (MIPS), we examined the first (2019) round of MIPS performance data for 510,020 clinicians. Compared with clinicians with the lowest socially at-risk caseloads, those with the highest had 13.4 points lower MIPS performance scores, were 99 percent more likely to receive a negative payment adjustment, and were 52 percent less likely to receive an exceptional performance bonus payment. The lower performance scores were partly explained by lower clinician reporting of and performance on technology-dependent measures, which may reflect a lack of practice-level technological capability. If the Complex Patient Bonus were in effect, the performance scores and likelihood of receiving an exceptional performance bonus (payment of clinicians with the highest socially at-risk caseloads) would have increased by 4.7 percent and 2.8 percent, respectively; however, the proportion receiving negative payment adjustments would have remained unchanged. The Complex Patient Bonus appears unlikely to mitigate the most regressive effects of MIPS.”

The article’s authors state that, “Medicare has recently implemented national, mandatory value-based payment programs in the outpatient setting. In 2019 nearly all clinicians in the US were reimbursed for the first time under the Merit-based Incentive Payment System (MIPS), earning negative and positive payment adjustments of up to 4 percent of their total reimbursement based on their performance scores. MIPS performance scores ranged from 0 to 100. Clinicians with scores lower than 3 did not meet reporting requirements and received negative payment adjustments, clinicians with scores higher than 3 received positive payment adjustments, and clinicians with scores of at least 70 also received exceptional performance bonus payments. Clinicians with scores of exactly 3 received no payment adjustments. The Centers for Medicare and Medicaid Services (CMS) reported that 5 percent of clinicians participating in 2019 received a negative payment adjustment and 71 percent received both a positive payment adjustment and an exceptional performance bonus.4 In future years CMS will increase the score thresholds, which makes it more difficult to avoid negative payment adjustments and obtain positive payment adjustments or exceptional performance bonus payments.”

There are levels and dimensions of complexity involved. As the authors note, “Clinicians participate in MIPS under one of two tracks. The first is the default track for all clinicians reporting to MIPS as individual entities or as part of group practices. The second is the Alternative Payment Models track, which features models such as the Medicare Shared Savings Program. Clinicians participating in either track have their performance scored from a set of nearly 400 measures that assess clinician- and practice-level processes and outcomes of care. Cost-of-care measures are being added to performance assessment in 2020.”

As if all that were not challenging enough, the factors involving social risk are not fully understood. As the authors write, “It is unknown how clinicians who largely serve patients with social risk factors such as low income fare under MIPS. Prior studies of the Medicare Value-Based Modifier program, the precursor to MIPS, suggest that such clinicians may perform worse than their peers. In addition, recent evidence has shown that hospital-based value-based payment programs tend to disproportionately penalize sites for serving low-income patients rather than for poor quality of care.10–14 In response to this research and concerns that clinicians serving the most vulnerable patients would be systematically underpaid, CMS added the Complex Patient Bonus to MIPS; it will be instituted in the 2021 payment year, based on 2019 clinician performance data.15 The bonus adds up to five points to clinicians’ final MIPS scores based on the medical complexity of their patients and the proportion of socially at-risk patients (defined as those dually enrolled in Medicare and Medicaid) whom they treat.”

It is in that context that the researchers studied outcomes under the program, using sophisticated methodologies. “We computed descriptive statistics on clinicians’ MIPS performance scores and payment indicators, as well as their individual, practice, patient caseload, and local practice area characteristics, comparing mean scores for clinicians with high versus low patient social-risk caseloads,” the authors write. “We did this for clinicians’ actual MIPS performance in 2019, as well as their hypothetical performance with the Complex Patient Bonus. Next, we estimated four clinician-level multivariable regression models to assess the association between social-risk caseload and actual 2019 MIPS outcomes. In model 1 we used ordinary least squares regression with the final MIPS score as the dependent variable; in models 2–4 we used logistic regression with indicators for a negative adjustment, positive adjustment, and exceptional performance bonus payment as the dependent variables. All models adjusted for the individual, practice, patient caseload, and local practice area characteristics listed here.” So what did they find?

“Clinicians with high social-risk caseloads received lower mean final 2019 MIPS scores (63 versus 73), a greater number of negative payment adjustments (11 percent versus 6 percent), fewer positive payment adjustments (86 percent versus 90 percent), and fewer exceptional performance bonus payments (57 percent versus 70 percent) than clinicians with low social-risk caseloads (exhibit 2). With the Complex Patient Bonus, clinicians with high social-risk caseloads still received lower mean final scores (66 versus 74), fewer positive payment adjustments (89 percent versus 94 percent), and fewer exceptional performance bonus payments (59 percent versus 70 percent) than clinicians with low social-risk caseloads. The proportion receiving negative payment adjustments remained unchanged.”

As a result, they write, “Outpatient clinicians who treated a disproportionately high percentage of socially at-risk Medicare beneficiaries performed worse in the 2019 MIPS and received unfavorable value-based reimbursement relative to their peers whose caseloads included a low percentage of such beneficiaries. Had it existed in 2019, the Complex Patient Bonus would have had very little impact on these differences, because it will be unavailable to clinicians who lack the resources to report performance measures to CMS. As a result, our findings suggest that the Complex Patient Bonus is unlikely to mitigate the most regressive effects of MIPS.”