Top Challenges of the Merit-Based Incentive Payment System

The Government Accountability Office (GAO) analyzed performance data from providers who participated in the Merit-Based Incentive Payment System (MIPS) between 2017 and 2019 and found that some providers experienced MIPS challenges.

Under MIPS, CMS monitors provider performance in four different categories: quality, improvement activities, promoting interoperability, and cost. The providers receive scores in each category, which determines if they earn a negative, neutral, or positive payment adjustment to future Medicare payments.

Most of the providers between 2017 and 2019 received a small positive payment adjustment, GAO found.

GAO interviewed 11 provider groups that participated in MIPS to gather feedback about the program. Providers mentioned several challenges they encountered during their participation.

Ten groups reported that performance feedback from CMS was not timely or meaningful for some providers.

CMS provides feedback for each performance category the accompanying scores, but some stakeholders said that the feedback for the previous year arrives too late and providers do not have enough time to modify their performance for the current year.

For 2021 performance, providers must submit data to CMS by March 2022, and CMS will provide feedback to providers in July 2022.

Some provider groups said that more frequent feedback from CMS would help them identify issues and make changes earlier in the year. However, in order for CMS to provide more timely feedback, providers must submit additional data throughout the performance year instead of waiting until the year is over, according to CMS officials, which may increase burden for providers.

Provider groups also told GAO that CMS feedback was not always relevant to their practices. They suggested that CMS provide comparative data on how providers are performing in relation to other similar providers. Larger practices with multiple specialties may report measures that increase their MIPS scores but are not relevant to all specialties in the practices, some groups noted.

CMS plans to address part of the issue with the MIPS Value Pathways (MVP) in 2023, which will allow providers to report performance measures that are relevant to a certain specialty or medical condition.

This reporting, along with subgroup reporting, would allow CMS to offer more comprehensive and targeted feedback to providers, the agency said.

Eight provider groups saw challenges surrounding the correlation between scores and quality of care. They questioned whether the program helps improve patient outcomes or if it simply incentivizes providers to focus on reporting instead of improvement.

MIPS scores may not accurately reflect care quality if providers are only reporting on performance measures that they see success with or are easy to achieve, some stakeholders noted.

Provider groups also told GAO that some quality measures assess activities that are not common for all specialties. Some providers may perform certain treatments frequently but may not receive an assessment for them.

“Stakeholders suggested that CMS could provide more information on how MIPS measures may improve quality of care or patient outcomes,” GAO wrote. “According to the preamble to the 2022 proposed rule, the MVP framework will help to address some of these challenges by standardizing performance measurement across specific specialties, medical conditions, or episodes of care.”

Lastly, stakeholders cited return on investment as a MIPS challenge. Eight groups reported that the payment adjustments received for good scores are not enough to cover the financial and administrative costs that result from participating in the program.

Providers may increase their spending to train staff and acquire technology resources to comply with the MIPS program requirements. For some stakeholders, the resulting payment adjustment does not make up for the high costs.

The CMS 2022 proposed rule plans to raise the performance threshold, which will reduce the number of providers who qualify for a positive payment adjustment, leading to a higher adjustment amount.

Despite the challenges, some provider groups cited positive aspects of the MIPS program as well. Some stakeholders said that performance category exemption, which allows providers to be exempt from reporting measures for one or more performance categories during the year, helped reduce participation burden.

Two stakeholders reported that the MIPS low-volume patient, service, and billing requirements also helped reduce participation burden.

Two provider groups said that bonus points for small practices and complex patients helped increase scores for providers who might have otherwise been at a disadvantage.