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Association Between Patient Social Risk and Physician Performance Scores in the First Year of the Merit-based Incentive Payment System

Educational Objective
To understand the relationship between physicians' performance in the Merit-based Incentive Payment System and the proportion of socially disadvantaged patients the physicians cared for.
1 Credit CME
Key Points

Question  Was there an association between patient social risk and physician performance in the first year of the Merit-based Incentive Payment System (MIPS), a major Medicare value-based payment program?

Findings  In this cross-sectional observational study of 284 544 physicians, physicians with the highest proportion of patients dually eligible for Medicare and Medicaid had significantly lower MIPS scores compared with physicians with the lowest proportion (mean, 64.7 vs 75.9; range, 0-100; higher scores reflect better performance).

Meaning  Physicians with the highest proportion of socially disadvantaged patients had significantly lower MIPS scores, although further research is needed to understand the reasons underlying the differences in MIPS scores by levels of patient social risk.

Abstract

Importance  The US Merit-based Incentive Payment System (MIPS) is a major Medicare value-based payment program aimed at improving quality and reducing costs. Little is known about how physicians’ performance varies by social risk of their patients.

Objective  To determine the relationship between patient social risk and physicians’ scores in the first year of MIPS.

Design, Setting, and Participants  Cross-sectional study of physicians participating in MIPS in 2017.

Exposures  Physicians in the highest quintile of proportion of dually eligible patients served; physicians in the 3 middle quintiles; and physicians in the lowest quintile.

Main Outcomes and Measures  The primary outcome was the 2017 composite MIPS score (range, 0-100; higher scores indicate better performance). Payment rates were adjusted –4% to 4% based on scores.

Results  The final sample included 284 544 physicians (76.1% men, 60.1% with ≥20 years in practice, 11.9% in rural location, 26.8% hospital-based, and 24.6% in primary care). The mean composite MIPS score was 73.3. Physicians in the highest risk quintile cared for 52.0% of dually eligible patients; those in the 3 middle risk quintiles, 21.8%; and those in the lowest risk quintile, 6.6%. After adjusting for medical complexity, the mean MIPS score for physicians in the highest risk quintile (64.7) was lower relative to scores for physicians in the middle 3 (75.4) and lowest (75.9) risk quintiles (difference for highest vs middle 3, –10.7 [95% CI, –11.0 to –10.4]; highest vs lowest, –11.2 [95% CI, –11.6 to –10.8]; P < .001). This relationship was found across specialties except psychiatry. Compared with physicians in the lowest risk quintile, physicians in the highest risk quintile were more likely to work in rural areas (12.7% vs 6.4%; difference, 6.3 percentage points [95% CI, 6.0 to 6.7]; P < .001) but less likely to care for more than 1000 Medicare beneficiaries (9.4% vs 17.8%; difference, –8.3 percentage points [95% CI, –8.7 to –8.0]; P < .001) or to have more than 20 years in practice (56.7% vs 70.6%; difference, –13.9 percentage points [95% CI, –14.4 to –13.3]; P < .001). For physicians in the highest risk quintile, several characteristics were associated with higher MIPS scores, including practicing in a larger group (mean score, 82.4 for more than 50 physicians vs 46.1 for 1-5 physicians; difference, 36.2 [95% CI, 35.3 to 37.2]; P < .001) and reporting through an alternative payment model (mean score, 79.5 for alternative payment model vs 59.9 for reporting as individual; difference, 19.7 [95% CI, 18.9 to 20.4]; P < .001).

Conclusions and Relevance  In this cross-sectional analysis of physicians who participated in the first year of the Medicare MIPS program, physicians with the highest proportion of patients dually eligible for Medicare and Medicaid had significantly lower MIPS scores compared with other physicians. Further research is needed to understand the reasons underlying the differences in physician MIPS scores by levels of patient social risk.

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Article Information

Corresponding Author: Dhruv Khullar, MD, MPP, Department of Population Health Sciences, Department of Medicine, Weill Cornell Medical College, 402 E 67th St, New York, NY 10065 (Khd9010@med.cornell.edu).

Accepted for Publication: July 6, 2020.

Author Contributions: Drs Schpero and Bond had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Khullar, Schpero, Bond, Casalino.

Acquisition, analysis, or interpretation of data: Khullar, Schpero, Bond, Qian.

Drafting of the manuscript: Khullar, Schpero, Bond.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Schpero, Bond, Qian.

Obtained funding: Casalino.

Administrative, technical, or material support: Bond, Qian.

Supervision: Khullar, Casalino.

Conflict of Interest Disclosures: Dr Khullar reported receiving grants from the American Medical Association and from the Patient-Centered Outcomes Research Institute (PCORI), outside this work. Dr Bond reported receiving grants from Arnold Ventures. Dr Casalino reported receiving personal fees from the Medicare Payment Advisory Commission and receiving an honorarium for participating until December 2019 in quarterly meetings as a member of the American Medical Association Professional Satisfaction and Practice Sustainability Advisory Committee. Dr Schpero reported receiving grants from PCORI, outside this work. No other disclosures were reported.

Funding/Support: This work was supported by the Physicians Foundation Center for the Study of Physician Practice and Leadership at Weill Cornell Medicine.

Role of the Funder/Sponsor: The Physicians Foundation Center had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Rebecca Onie, JD, and Rocco Perla, EdD, of The Health Initiative for conversations motivating this work and for their thoughtful comments on a prior draft of this article. They did not receive compensation for their involvement.

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