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Invited Commentary
May 14, 2021

Cost of Compliance With CMS Physician Quality Monitoring—Too High?

Author Affiliations
  • 1Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
JAMA Health Forum. 2021;2(5):e210684. doi:10.1001/jamahealthforum.2021.0684

In a qualitative study published in this issue of JAMA Health Forum, Khullar and colleagues1 do an excellent job of providing insight into the cost burden of compliance with the US Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS). The authors were detailed in their approach, which is commendable as fleshing out cost data for quality program compliance is notoriously difficult. What the authors present is a per physician cost perspective of compliance. While this serves some purpose, an alternate approach that may lay bare the issue for policy makers is to look at what proportion of the CMS reimbursement per Medicare visit is consumed by quality-reporting compliance costs. The reason this is important relates to understanding what it costs to monitor and ensure quality from a per patient-visit perspective.

Khullar and colleagues1 estimate a $12 000 per physician annual cost of compliance with the MIPS program. Consider a conservative estimate of a primary care physician panel of 1200 patients per year with 2.5 visits per patient; previous research suggests2 an average of 1400 patient panels per physician, each with approximately 3 visits. On average, one-third of these patients would be Medicare recipients,3 although for some specialties, the proportion may be much larger according to information cited by the authors. In this scenario, 1000 office visits a year would be with Medicare recipients. Spread across 1000 visits, the $12 000 cost of MIPS compliance would be approximately $12 per visit at the mean, based on the authors’ estimates.1 Applying this calculation and the reimbursement amount for visits for established patients with low complexity (Current Procedural Terminology code 99213 ), for which CMS reimbursement was approximately $90 per visit, implies that approximately 13% of each reimbursement would pay for quality monitoring.

This calculation brings up multiple questions. First, is 13% of revenue from Medicare visits too much to ask physicians to bear to comply with CMS quality-monitoring programs? One way to think about it is to ask if legislation instituting a direct 13% fee-cut to primary care physician visits would survive the US Congress. Unlikely.

Second, should CMS increase reimbursements to cover some or all of the cost burden? Without a clear understanding of what that revenue buys in terms of improved patient care, a 13% increase in reimbursement to support compliance might be just as politically untenable as a 13% cut.

The path forward on this is not going to be easy, but these sorts of questions need to be addressed, and quickly. As is clear from Duseja and colleagues,3 who describe episode-based cost measures in this issue of JAMA Health Forum, that under the next iterations of MIPS the complexity of quality reporting is not going to lessen. Increased complexity will certainly raise the cost of quality monitoring even further. The lingering question is whether CMS can continue to raise the cost of compliance without being explicit about who is paying for what portions of the burden.

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Article Information

Published: May 14, 2021. doi:10.1001/jamahealthforum.2021.0684

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Hockenberry JM. JAMA Health Forum.

Corresponding Author: Jason M. Hockenberry, PhD, Department of Health Policy and Management, Yale School of Public Health, 60 College St, New Haven, CT 06510 (jason.hockenberry@yale.edu).

Conflict of Interest Disclosures: None reported.

Khullar  D, Bond  AM, O’Donnell  EM, Qian  Y, Gans  DN, Casalino  LP.  Time and financial costs for physician practices to participate in the Medicare Merit-based Incentive Payment System: a qualitative study.   JAMA Health Forum. 2021;2(5):e210527. doi:10.1001/jamahealthforum.2021.0527Google Scholar
Murray  M, Davies  M, Boushon  B.  Panel size: how many patients can one doctor manage?   Fam Pract Manag. 2007;14(4):44-51.PubMedGoogle Scholar
Duseja  R, Andress  J, Sandhu  AT,  et al.  Development of episode-based cost measures for the US Medicare Merit-based Incentive Payment System.   JAMA Health Forum. 2021;2(5):e210451. doi:10.1001/jamahealthforum.2021.0451Google Scholar
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