Quality Commitment Doesn’t Always Pay Out in MIPS

By Elizabeth Y. Rula, PhD, Executive Director of the Harvey L. Neiman Health Policy Institute®

Research Rounds

This column highlights the Harvey L. Neiman Health Policy Institute® (HPI) research that reveals radiologists’ challenges in the Medicare Merit-based Incentive Payment System (MIPS). With each challenge comes an opportunity; in this case, our goal is to provide a foundation for policy change that will help ACR members benefit more fully from providing high-quality care.

MIPS is the largest CMS Quality Payment Program (QPP), a major effort to overhaul Medicare’s payments and incentivize quality over quantity of care. The Medicare Access and CHIP Reauthorization Act of 2015 required that CMS create the QPP, which launched in 2017. The program’s goal is to establish a reimbursement model that rewards clinicians who provide high-quality and cost-effective patient-centered care. It pays for these bonuses by reducing payments to physicians who do not meet quality and cost standards.

Physicians who participate in Medicare are generally required to participate in the QPP — either through MIPS or an Advanced Alternative Payment Model (APM). Most radiologists participate in MIPS, which means that their Medicare Part B reimbursement can increase or decrease depending on their performance compared to benchmarks in categories of the QPP for which they are eligible. The Quality Category of MIPS is the largest contributor to most radiologists’ final bonus or penalty, representing 85% of the total MIPS score for the majority of radiologists.

There is no doubt that ACR members are committed to quality care, and many contribute to quality improvement through ACR Quality and Safety programs. Yet, the data make it evident that radiologists have limited opportunities to demonstrate their quality performance via MIPS, especially radiologists in small or radiology-only practices. Our JACR study published in February found that radiologists’ participation type (individual, group or APM) and their practice size were the two strongest predictors of MIPS performance. 

Our study including all 23,875 MIPS radiologists showed that only 43% of individual radiologists scored “exceptional” in 2019, qualifying for an additional performance bonus, versus 99% in APMs. Most radiologists participate in MIPS via group reporting, and this cohort’s performance fell in the middle, but closer to the APM group. Specifically, individually reporting radiologists scored 32% lower, while APM radiologists scored 8% higher than the average for group reporting. Moreover, individually reporting radiologists were 7.4 times more likely to not achieve “exceptional” status (and qualify for the highest bonuses) than group-reporting radiologists, so this issue hits the bottom line.

The study also found that practices with less than 50 clinicians were more likely to underperform in MIPS, whereas hospital-based radiologists were less than half as likely to underperform in MIPS. “Despite CMS’ efforts to support smaller-practice MIPS success with bonus points and reduced reporting requirements, smaller practices remain disadvantaged. Yet, evidence does not support that smaller practices provide lower-quality care,” said lead researcher YoonKyung Chung, PhD, principal researcher at the HPI. Additional significant predictors of underperformance in MIPS were more rural practices, higher-risk patients, and more years in practice (>10 versus <10).

The underperformance of small practice radiologists in MIPS invites the question of why this is happening. Another HPI study, published in the American Journal of Roentgenology in 2024, helps answer that question. Our research team focused on the specialty mix of radiologists’ practices and how that related to MIPS reporting and resulting scores. The results helped explain the disadvantage. Radiologists in multispecialty practices (often larger in size) score significantly higher than those in radiology-only or -majority practices but rarely report any radiology-relevant MIPS quality measures. Instead, as allowed in the MIPS program, radiologists in multispecialty practices typically report measures relevant to other specialties — piggybacking on the larger set of metrics available to the practice versus the very few radiology metrics. For example, diagnostic radiology had only nine quality measures in the study year of 2021 (six in 2024) and are required to report six measures. In comparison, family medicine had 65 measures in traditional MIPS.

When evaluating the top 10 measures reported most frequently by radiologists in each practice type, the results were striking: For radiologists in a multispecialty practice that wasn’t mostly radiologists, not a single radiology-focused measure was among that list. The opportunity to report non-radiology measures also translated to differences in scores. Radiologists’ mean MIPS final score and quality score were both lowest for radiology-only practices (78.3 and 59.7) and highest for no-majority multispecialty practices (89.1 and 75.4). Overall, radiologists scored well in MIPS, but this success was largely dependent upon whether a radiologist was or was not limited to radiology-specific measures.

Another challenge for radiologists to achieve high scores and bonuses is that, of the very few available measures, most are topped-out, meaning that a full bonus isn’t possible because average scores are too high. In fact, none of the top 10 quality measures reported by individual and group participants in our 2025 study were still available for full-score potential in 2024. It is unsurprising that radiologists in multispecialty groups or APMs take advantage of the opportunity to report measures of other medical specialties within their practice.

According to MIPS expert and co-author on both HPI studies, Lauren P. Nicola, MD, FACR, CEO of Triad Radiology Associates and ACR Commission on Economics member, “Our study sends a clear message: the MIPS program in its current design will not move the needle on quality in radiology. For MIPS to work as intended, physicians must report measures relevant to their specialty, which will require more measures that reflect the quality of care that radiologists provide.”

Although the challenges cannot be ignored and must be addressed through policy, there is another reporting pathway that is more advantageous for radiologists: participation via a CMS-approved MIPS qualified clinical data registries (QCDR) such as the ACR National Radiology Data Registry. There were 20 diagnostic radiology QCDR measures in 2024, of which 14 allow for maximum points. The Quality and Safety team at ACR works tirelessly to identify, test and propose new measures, which will help toward the goal of MIPS reporting that adequately distinguishes differences in quality, and that allows radiologists to earn bonuses by reporting measures based on their own work.

Thanks to years of ACR advocacy, CMS has finally acknowledged the disadvantage that a limited pool of predominantly topped-out measures presents for radiology. Recent policy changes from the agency have been implemented to reduce the impact of topped out measures. For 2025, CMS removed the 7-point scoring cap for several of the topped-out measures within specialty measure sets with a limited number of applicable measures. Instead of a scoring cap, adjustments are made to the benchmarks of topped-out measures to allow for a maximum score of 10 points. The 2026 proposed rule extends this provision. While these changes provide a helpful patch for the topped-out measure issue, larger reform will be necessary in order for the MIPS program to succeed in promoting quality in radiology.

To read more about the HPI studies on MIPS, see the press releases on practice specialty mix and on reporting type and practice size, both available at www.neimanhpi.org.