Replacement of Medicare’s MIPS Program
The Merit-based Incentive Payment System (MIPS) was established by the Centers for Medicare and Medicaid Services (CMS) through the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. As part of the Quality Payment Program (QPP) under MACRA, MIPS was intended to financially reward Medicare providers (who are reimbursed under Medicare Part B covered professional services) for patient care improvement from volume-based care to value-based care. This is through the use of a combined performance score of 0-100 based on four categories: quality measures, cost measures, promotion of interoperability and practice improvement activities. Eligible Medicare providers that meet or exceed MIPS measure thresholds receive a payment bonus, while those providers that do not meet or exceed those thresholds receive a penalty or no adjustment. There is a two-year gap between a performance reporting year and a payment year. For the 2025 reporting year/2027 payment year, the threshold remains at 75 points. This program is designed to be budget-neutral, meaning the funds available cannot exceed the penalties imposed.
Several studies and medical association evaluations, including a 2022 study by the American Medical Association (AMA) evaluated MIPS scores of more than 80,000 primary care providers for 3.4 million patients. Findings revealed MIPS scores were “inconsistent related to performance on process and outcome measures”, meaning MIPS may not be a reliable indicator of a physician’s clinical performance or an effective way to incentivize quality improvement among U.S. physicians.
Key issues in the current MIPS measurement design include physicians who are often penalized for providing high quality of care to sicker or marginalized patients; smaller practices and rural-based practices struggling to meet MIPS requirements are often penalized more than larger, health system-backed physician practices; and MIPS measurements are more relevant to primary care than other specialties. According to CMS’ 2022 Quality Payment Program Experience, 27 percent of small physician practices were penalized; 18 percent of rural physician practices were penalized; nearly 30 percent of physicians in solo practice received the maximum 9 percent penalty; and anesthesiology and orthopedic surgery were among the specialties with the highest proportion of physicians receiving a penalty.
In addition, MIPS presents a heavy financial and administrative burden for physician practices. In a 2021 study by the AMA, 30 physician practices across the U.S. were interviewed. Findings revealed an average of $12,811 per physician was spent to be MIPS compliant, and 202 hours per year was spent on MIPS-related activities.
Currently there are three MIPS reporting options available: traditional MIPS, Alternative Payment Model (APM) Performance Pathway (APP) and MIPS Value Pathways (MVPs). As the newest MIPS reporting option, CMS created the MVPs program as an alternative to eventually replace MIPS. The groundwork for the MVPs program includes a subset of measures and activities related to certain specialties and medical conditions such as emergency medicine, oncology, cardiology and vascular surgery, just to name a few. In addition, each MVP includes population health measures, promoting inoperability performance category objectives and measures, and potential physician specialty recommendations so physicians have an idea of the best-suited MVP for their reporting.
As CMS continues to develop and maintain the MVPs program, MVPs reporting is optional. However, CMS intends to sunset traditional MIPS through future rulemaking and encourages early adoption of MVPs reporting so physicians can get familiar with the program before reporting through MVPs becomes mandatory.
