Payment & Delivery Models

Medicare Basics series: MIPS data problems

. 5 MIN READ

Value-based care relies on data. To be successful, physicians in Medicare’s Merit-based Incentive Payment System (MIPS) need access to a wide range of information on a timely basis to understand gaps in care and identify opportunities to improve health outcomes, reduce variations in care delivery or eliminate avoidable services—all steps that can lower costs for patients and the Medicare program.

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While Congress recognized the critical importance of data sharing with physicians in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) statute that created MIPS by requiring timely performance feedback, the Centers for Medicare & Medicaid Services (CMS) has dragged its feet in meeting its statutory obligation. The agency has never provided Medicare claims data to physicians, even though the requirement went into effect in 2018. The lack of timely and actionable feedback contributes to physicians’ frustration with the MIPS program, which they experience as another check-the-box exercise rather than an actionable effort to improve quality and reduce costs.

CMS provides physicians with an annual MIPS Feedback Report that includes information about their performance on MIPS metrics six to 18 months after they provided a service to a Medicare patient. For example, the first MIPS Feedback Report that physicians received for services they provided anytime in 2021 was August 2022. This includes performance information on up to 25 cost measures CMS calculates for each physician using Medicare claims data. Physicians do not know at the time they provide a service or at any point during the performance year how they are performing on any of these measures that collectively account for 30% of their total MIPS score. They do not know in advance which cost measures they will be measured on, which patients are attributed to them, and for what costs or services provided by other health professionals or facilities outside of their own practices they will be held accountable.

Without this information physicians have no way to monitor their performance, identify opportunities for efficiencies in care delivery and avoid unnecessary costs. This is not due to a lack of interest in the information. Physicians have repeatedly urged (PDF) CMS to share more frequent and actionable data.

CMS releases an annual overview of data collected through its Medicare Quality Payment Program (QPP), including MIPS and alternative payment model data, and the number of physicians who will receive a MIPS bonus or penalty. Known as the QPP Experience Report, the data it provides are of limited use. For example, the same physician can be counted multiple times if they bill for services through multiple organizations. A physician can have a low MIPS score for one practice and a high MIPS score for another practice resulting in multiple, completely different publicly reported scores. Moreover, CMS does not break down performance by specialty, site of service, or reporting mechanism/type. The report also fails to show any longitudinal trends about whether quality or cost are improving or declining, nor does it provide a complete picture of what made a physician or group practice successful in MIPS. Physicians have repeatedly called (PDF) for these details to inform quality improvement efforts and future measure development.

In addition, CMS also releases public use data files that include more detailed information about MIPS. These reports, which are generally used for research purposes, have contributed to important findings, such as a recent study in JAMA that concluded MIPS scores are inconsistently related to performance. Further, physicians caring for more medically and socially vulnerable patients are more likely to receive low scores despite providing high-quality care, which could have serious unintended consequences by lowering payments for safety net physicians treating high-risk patient populations. The American Medical Association’s own analysis of several MIPS data files found that they are incomplete and inconsistent. As a result, it is difficult to drill down into the data to better understand how small practices and rural practices, for example, are performing in MIPS and why this might be the case. Ensuring that data are accurate is critically important to ongoing efforts to understand and improve this program.

  • Direct CMS to improve timely access to MIPS feedback reports and claims data as required by MACRA.
  • Exempt from MIPS penalties any physician who does not receive at least three quarterly MIPS feedback reports during the performance period.

The AMA's Medicare Basics series provides an in-depth look at important elements of the Medicare physician payment system. Find more topics about the payment system and why it's in need of reform.  

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