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Original Investigation
August 11, 2021

Evaluation of the Merit-Based Incentive Payment System and Surgeons Caring for Patients at High Social Risk

Author Affiliations
  • 1Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
  • 2Department of Surgery, The University of Texas Southwestern Medical School, Dallas
JAMA Surg. Published online August 11, 2021. doi:10.1001/jamasurg.2021.3746
Key Points

Question  Is the Merit-Based Incentive Payment System (MIPS) disproportionately penalizing surgeons serving patients at high social risk?

Findings  In this cohort study of 10 252 general surgeons who participated in the first year of MIPS, surgeons with patients in the highest quintile of social risk had a caseload with at least 37% of Medicare patients dual eligible for Medicare and Medicaid. Caring for patients at high social risk was associated with the lowest MIPS scores and a significantly increased risk of a negative payment adjustment.

Meaning  In this study, surgeons caring for patients at highest social risk received lower MIPS scores and had an increased risk of negative payment adjustment, despite ongoing efforts to target surgical disparities.

Abstract

Importance  The latest step in the Centers for Medicaid & Medicare transformation to pay-for-value is the Medicare Merit-Based Incentive Payment System (MIPS). Value-based payment designs often do not account for uncaptured clinical status and social determinants of health in patients at high social risk, and the consequences for clinicians and patients associated with their use have not been explored.

Objective  To evaluate MIPS scoring of surgeons caring for patients at high social risk to determine whether this implementation threatens disadvantaged patients’ access to surgical care.

Design, Setting, and Participants  A retrospective cohort study of US general surgeons participating in MIPS during its first year in outpatient surgical practices across the US and territories. The study was conducted from September 1, 2020, to May 1, 2021. Data were analyzed from November 1, 2020, to March 30, 2021 (although data were collected during the 2017 calendar year and reported ahead of 2019 payment adjustments).

Main Outcomes and Measures  Characteristics of surgeons participating in MIPS, overall MIPS score assigned to clinician. and practice-level disadvantage measures. The MIPS scores can range from 0 to 100. For the first year, a score of less than 3 led to negative payment adjustment; a score of greater than 3 but less than 70 to a positive adjustment; and a score of 70 or higher to the exceptional performance bonus.

Results  Of 20 593 general surgeons, 10 252 participated in the first year of MIPS. Surgeons with complete patient data (n = 9867) were evaluated and a wide range of dual-eligible patient caseloads from 0% to 96% (mean [SD], 27.1% [14.5%]) was identified. Surgeons in the highest quintile of dual eligibility cared for a Medicare patient caseload ranging from 37% to 96% dual eligible for Medicare and Medicaid. Surgeons caring for the patients at highest social risk had the lowest final mean (SD) MIPS score compared with the surgeons caring for the patients at least social risk (66.8 [37.3] vs 71.2 [35.9]; P < .001).

Conclusions and Relevance  Results of this cohort study suggest that implementation of MIPS value-based care reimbursement without adjustment for caseload of patients at high social risk may penalize surgeons who care for patients at highest social risk.

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