ACR Bulletin

Covering topics relevant to the practice of radiology

The Unraveling of MIPS

Radiologists should look for ways to incorporate measures that incentivize the reduction of disparities and improve patients’ access to high-quality care.
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One clear opportunity for improvement in the remaking of MIPS would be to include measures that address the disparities in healthcare.

—Lauren P. Golding, MD
March 25, 2021
Most radiologists are familiar with the acronym-laden MACRA legislation and its offspring, the Quality Payment Program (QPP). Now entering its fifth year, the QPP, in many ways, has fallen short of achieving its goals of improving quality and reducing the cost of healthcare. Widespread criticism of the QPP and its pay-for-performance arm, the Merit-Based Incentive Payment System (MIPS), has escalated over the program’s short lifespan. Critics point to the overly burdensome reporting requirements, the difficulty in comparatively scoring clinicians across specialties on different measures, and the financial resources required to “play the game” successfully.
CMS responded to criticism of MIPS by changing the program in ways intended to reduce burden and increase focus on improving outcomes of patient care. Some of these updates to MIPS include the “Patients over Paperwork” initiative — in which CMS reduces the number of available quality measures by removing measures felt to be too easy, low-value, or focused on process improvement instead of patient outcomes. Unfortunately, these changes come with consequences that do little to substantially improve the program and specifically disadvantage radiologists.1 The only ways for radiologists to score perfectly in MIPS — allowing them to share in the maximum exceptional performance bonus — are to either make up the gap in their quality score by accruing bonus points for submitting extra high-priority measures, submitting measures using end-to-end electronic reporting, or reporting non-capped measures using a qualified clinical data registry (QCDR), such as the ACR’s National Radiology Data Registry.
QCDRs have their own challenges with strict and ever-changing CMS approval requirements and a labor-intensive measure development process. Another revision to MIPS was the implementation of a new participation framework called the MIPS Value Pathways (MVPs) that was initially slated to begin in the 2021 performance period but has been delayed until 2022. The goal of MVPs is to move away from siloed activities and measures in the four relatively unrelated MIPS performance categories and move toward an aligned measure set to better prepare clinicians for alternative payment models (APMs). The applicability of MVPs to radiologists is not yet clear. In the absence of meaningful quality and cost measures, the MVP framework is unlikely to solve the problems of MIPS.
The shortcomings of MIPS predated COVID-19, but the pandemic further exacerbated its unraveling. The last thing physicians have had on their minds over the past year is satisfying complex reporting requirements and devising scoring strategies. To the credit of CMS, the agency recognized this and agreed to hold clinicians harmless from a negative payment adjustment for the 2019 and 2020 payment years. However, this too has detrimental consequences to the program. Because MIPS is a zero-sum game in which the losers pay the winners, removing all risk of losing means there is no money available to pay the winners and negates the entire pay-for-performance paradigm. With already minuscule bonuses for high performers in 2017 and 2018, further dilution of the available bonus pool does nothing to incentivize buy-in from clinicians trying to maximize their performance in MIPS. Furthermore, by exempting large numbers of clinicians from MIPS in 2019 and 2020, many of the quality measures will no longer have historical benchmarks — leaving CMS unable to score measures that have always been plagued by imprecision and questionable relevance. By statutory requirement, MIPS will reach its full implementation next year with the 2022 performance period. This means that in the absence of legislative intervention, the performance threshold — or the score below which a clinician receives a negative payment adjustment — must be set at either the mean or median of all participants’ scores. In the aftermath of the pandemic, with no valid benchmarks and myriad uncertainties, such a high-performance threshold will be untenable.
One clear opportunity for improvement in the remaking of MIPS would be to include measures that address the disparities in healthcare. Although pay-for-performance programs may lead to overall improvements, there is some evidence to suggest that they may inadvertently exacerbate health disparities for marginalized populations.2 Certainly, small and rural practices have struggled to perform well in MIPS, despite provisions in scoring designed to level the playing field. Most MIPS measures capture clinical effectiveness, whereas few attempt to capture aspects of access, patient experience, or interpersonal care. These gaps suggest that MIPS, as it currently exists, may fail to measure the broader aspects of healthcare quality and may even risk worsening existing disparities.

  1. Golding LP,  Nicola GN, Duszak R, Rosenkrantz AB. The quality measure crunch: how CMS topped out scoring and removal policies disproportionately disadvantage radiologists. J Am Coll Radiol. 2020;17(1):110117.
  2. Casalino LP, Elster A, Eisenberg A, Lewis E, Montgomery J, Ramos D. Will pay-for-performance and quality reporting affect health care disparities? Health Aff (Millwood). 2007;26(3):w405w414.

Author Lauren P. Golding, MD,  ACR RUC Advisor