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Physicians score well in Quality Payment Program but receive little for it

Blog | hfma:content/topic/payment-reimbursement-and-managed-care/physician-payment-and-reimbursment

Physicians score well in Quality Payment Program but receive little for it

  • Ninety-seven percent of Merit-based Incentive Payment System (MIPS)-eligible clinicians submitted some data as an individual, group, virtual group or APM entity, according to a recent CMS report on the 2019 performance year, impacting the 2021 Physician Fee Schedule.
  • The vast majority of eligible physicians participating in MIPS also scored well, with 84% receiving an exceptional payment adjustment and 12% receiving a positive payment adjustment.
  • Small practices still struggle to participate — with only 85% of MIPS-eligible small practices participating — and tending to score worse than average as well, according to the latest CMS report.

Evidently, many physicians and clinicians are participating in the Quality Payment Program (QPP), but only to a point.

According to a recent CMS report on the 2019 performance year, impacting the 2021 Physician Fee Schedule (PFS) payments), 97%, or 954,000  Merit-based Incentive Payment System (MIPS)-eligible clinicians submitted some data as an individual, group, virtual group or APM entity. Not only did the vast majority of eligible physicians participate, but they scored well as follows:

  • 84% will receive an exceptional payment adjustment. 
  • 12% will receive a positive payment adjustment.
  • Only 4% will receive a neutral adjustment.
  • Less than 1% received a negative payment adjustment.

However, that performance isn’t translating into increased dollars in Fee for Service (FFS) payments.

MIPS is a budget-neutral program with the minimum/maximum bonus in 2021 capped at -/+9%. So like Hospital Value-Based Purchasing, payments to high performers are funded from payment reductions to underperformers.

Congress also sweetened the pot a bit for exceptional performers by appropriating $500 million per year through 2022 for a high-performance bonus. Unfortunately, for the 84% of MIPS-eligible providers who are exceptional, the payout’s not significant. The minimum adjustment for exceptional performers is .09% going up to a maximum 1.79%.

One might speculate that the COVID-19 PHE, which necessitated the use of CMS’s extreme and uncontrollable circumstances policies, might have reduced the pool of participants that scored poorly, contributing to the low bonus pool. However, this is not the case. The performance adjustment for 2021 is actually an increase from the CY2020 payout (based on 2018 performance) of 1.68%. The relatively low bonus pool is an intentional design. The program excludes a large percentage of smaller providers who, due to the complexity of the program, may not perform well.

Beyond MIPS, the number of providers who meet the threshold to qualify as an Advanced APM participant increased in 2019 to 195,564, up from 183,306 in 2018. These providers will receive a 5% increase in their Medicare FFS payments.

A few other observations include the following:                                                

Small practices: Small practices still struggle to participate — only 85% of MIPS-eligible small practices participated — and tend to score worse than average,   68.99 points, which is below the cutoff for the exceptional performance bonus. The mean score for all eligible participants in contrast was 85.55.  

Left out: CMS doesn’t provide details on the number of physicians who are not MIPS-eligible and did not participate. These are typically smaller practices and new providers. In the CY2019 proposed rule (for 2021 payment), CMS estimated that 677,000 physicians were not eligible for MIPS. While the policy exclusions for some of these providers may be merited due to the complexity of the program, that’s a large percentage of providers who are exempt from one of CMS’s biggest quality improvement programs.

Takeaway

The program needs to be simplified to allow all providers to participate without it being overly burdensome.  To the extent that the MIPS program actually drives performance improvement, the exclusions exclude a non-trivial number of beneficiaries from improved care.

Alternative Payment Model (APM) Participation: Approximately 416,000 MIPS-eligible providers (44% of total) participated through a MIPS-APM (e.g., MSSP). They tended to score better than their peers who did not participate through a MIPS-APM. Approximately 96% of MIPS APM participants scored above the exceptional performance bonus program versus 74% of MIPS-eligible participants who did not participate through an APM.  

Takeaway

I suspect that APM participants better performance is likely due to having the support/resources at the APM entity level to help address/relieve the administrative burden of participating. 

About the Author

Chad Mulvany, FHFMA,

is director, healthcare finance policy, strategy and development, HFMA’s Washington, D.C., office.

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