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Liao JM, Zhou L, Navathe AS. Group Practice Performance in the Second Year of Medicare’s Merit-Based Incentive Payment System. JAMA Netw Open. 2021;4(10):e2128267. doi:10.1001/jamanetworkopen.2021.28267
The Merit-Based Incentive Payment System (MIPS) program seeks to reward clinicians for practicing high-value care in the following 4 domains: quality, resource use, advancing care information, and improvement activities.1,2 A composite performance score is calculated and compared with a threshold score to positively or negatively adjust clinicians’ Medicare fee-for-service payment rates by up to 7% in 2021 and 9% in subsequent years.
In 2020, nearly 900 000 clinicians nationwide received MIPS payment adjustments based on 2018 performance. Because nearly 80% were part of group practices, and practices were evaluated using different criteria than individuals, understanding group performance is central to understanding overall MIPS performance. In 2019, the first year of MIPS adjustments, the composite score threshold was very lenient: Groups avoided penalties simply by reporting data, and the vast majority of groups were deemed exceptional performers. However, little is known about how groups fared as MIPS rules for 2020 adjustments became more stringent. The objective of this study was to describe performance among group practices in the second year of MIPS.
We conducted this cross-sectional study among group practices between March and July 2021. Our unit of analysis was the group practice. We linked 2018 MIPS group practice data with Physician Compare data to calculate practice size, urban or rural status, scope (single vs multispecialty), and practice Medicare population size and case mix (beneficiaries’ average Hierarchical Condition Category scores).2-4 We used county-level data to define characteristics of practices’ surrounding communities, including health care spending (Medicare per-beneficiary reimbursement), educational attainment (proportion of individuals with some college education), income (median household), and severe housing cost burden (proportion of individuals spending >50% of their income on housing).5 Study data were publicly available, and the University of Washington institutional review board waived approval per institutional policy. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline where appropriate.
Per Medicare rules, we categorized MIPS participants by composite score into negative (<15), neutral (15), positive (>15 and <70), and exceptional (≥70) performers. We conducted pairwise comparisons between exceptional and other performance categories using χ2 tests for categorical variables and Kruskal-Wallis tests for continuous variables. Statistical tests were 2-tailed and significant at α = .05. Analyses were performed in SAS, version 9.4 (SAS Institute Inc).
Our sample consisted of 17 201 group practices representing 700 706 clinicians. Of the 17 201 group practices, 66.2% were exceptional performers, 33.3% were positive performers, and very few were neutral (0.1%) or negative (0.5%) performers. The mean (SD) MIPS composite score was 76.0 (27.5), and the median (IQR) score was 89 (52.7-100.0) (Figure).
Across groups, 16 115 (93.7%) matched to Physician Compare and county-level data (Table). Most of these were small practices (11 083 [68.8%]) located in urban areas (13 638 [84.6%]) with college-educated individuals (median [IQR] of 65.7% [59.4%-71.3%] for residents with some college) without housing cost burden (median [IQR] of 14.4% [12.3%-17.4%] of residents experiencing severe housing cost burden). Most groups were multispecialty (11 391 [70.7%]).
Several characteristics varied by MIPS performance (Table). Compared with the 70 negative performers, the 10 761 exceptional performers had larger patient populations, with a median [IQR] of 4335 [1735-12 350] vs 2040 [841-10 184] patients. Compared with 5271 positive performers, more exceptional performers were small practices (7559 of 10 761 [70.2%] vs 3469 of 5271 [65.8%]). Exceptional performers also had lower proportions of Medicare/Medicaid dual-eligible patients (median [IQR] of 19.1% [10.4%-30.4%] vs 23.0% [13.5%-35.2%]) and Black patients (median [IQR] of 4.5% [1.5%-10.7%] vs 5.2% [1.7%-11.2%]) than positive performers. There were small differences in urban status, regional health care spending, and community-level educational attainment between positive and exceptional performers.
The findings of this cross-sectional study suggest that despite more stringent composite score thresholds for 2020 payment adjustments, most practices achieved exceptional performance. Similar to the preceding year, performance varied by practice factors.6 Study limitations included unavailable payment adjustment information, the inability to infer causality about practice factors associated with MIPS performance, exclusion of the small proportion of clinicians (21%) participating in MIPS outside of group practices, and use of community-level variables. Nonetheless, performance thresholds could be revised to avoid designating most practices as exceptional, thereby diluting its meaning and policy impact. Policy makers could also consider practice factors to make MIPS scoring more equitable.
Accepted for Publication: July 18, 2021.
Published: October 5, 2021. doi:10.1001/jamanetworkopen.2021.28267
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Liao JM et al. JAMA Network Open.
Corresponding Author: Joshua M. Liao, MD, MSc, Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195 (firstname.lastname@example.org).
Author Contributions: Drs Liao and Zhou had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Liao, Navathe.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Liao, Navathe.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Zhou, Navathe.
Obtained funding: Navathe.
Administrative, technical, or material support: Navathe.
Supervision: Liao, Navathe.
Conflict of Interest Disclosures: Dr Liao reported receiving personal fees from Kaiser Permanente Washington Health Research Institute, textbook royalties and honoraria from Wolters Kluwer, and honoraria from the American College of Physicians and Journal of Clinical Pathways outside the submitted work. Dr Navathe reported receiving grants from Anthem Public Policy Institute, Blue Cross Blue Shield of North Carolina, Blue Shield of California, Cigna Corporation, Commonwealth Fund, the Donaghue Foundation, the Hawaii Medical Service Association, Humana, the Ochsner Health System, Oscar Health, the Pennsylvania Department of Health, the Robert Wood Johnson Foundation, and United Healthcare; personal fees from Advocate Physician Partners, Agathos Inc, Analysis Group, Cleveland Clinic, Elsevier Press, the Maine Department of Health and Human Services, the Maine Health Accountable Care Organization, the Medicare Payment Advisory Commission, the Ministry of Health–Singapore, National University Health System–Singapore, Navahealth, Navvis Healthcare, VBID Health, and YNHHSC/CORE (Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation); and equity from Embedded Healthcare, Integrated Services Inc, and Navahealth outside the submitted work. No other disclosures were reported.
Disclaimer: This article does not necessarily represent the views of the US government or the Department of Veterans Affairs.