Editor’s Spotlight/Take 5: Are Quality Scores in the Centers for Medicaid and Medicare Services Merit-based Incentive Payment System Associated With Outcomes After Outpatient Orthopaedic Surgery?

Derek Schloemann MD, MPHSAsk a patient which physician they want, and they'll tell you they want the best. It would be pretty unusual for a patient to say, "I want someone who's adequate and within two standard deviations of the mean." (Which, as is turns out, is the vast majority of us.) Physician quality is, and always has been, important to patients. But measuring quality turns out to be difficult. And as we see in this month's Editor's Spotlight/Take 5 study in Clinical Orthopaedics and Related Research®, "Are Quality Scores in the Centers for Medicaid and Medicare Services Merit-based Incentive Payment System Associated With Outcomes After Outpatient Orthopaedic Surgery?" by Derek Schloemann and colleagues [6], there is very little relationship between how physicians scored on mandatory performance thresholds and how their patients did after surgery. As it happens, many of the metrics used for assessing physician quality aren't particularly useful. For an analogy, I considered how we think about hitters and batting averages in baseball. As Bill James (the sabermetrics guru) once wrote, "One absolutely cannot tell, by watching, the difference between a .300 hitter and a .275 hitter. The difference is one hit every two weeks" [5]. For those who don't follow baseball, a .275 hitter is substantially better than average, and a .300 hitter will probably wind up in the Hall of Fame. But success in any particular at-bat may depend on who's pitching, whether a fielder is in position, lighting conditions, and a host of variables that a hitter can't control. And if it's that hard to assess batters in a game that is played in front of thousands of fans, what chance do we have at assessing surgeons? But where there's a will, there's a way, and the federal government began assessing physician performance in 2017 through the Merit-based Incentive Payment System (MIPS, for short). MIPS provided two tracks for clinicians to participate in the Quality Payment Program under the 2015 Medicare and CHIP Reauthorization Act (MACRA). MIPS either rewards or penalizes clinicians annually based on performance in four domains: cost, quality, improvement activities, and promoting interoperability. Over the last several years, the federal government has changed the weighting for each domain, but "quality" currently represents 30% of the total. If clinicians score above a target on their MIPS score for the year, they get a small bonus; if they fall short, they get a "negative MIPS payment adjustment." Or, more plainly: a penalty. Clinicians found MIPS problematic from the start. It's time-consuming and expensive—physicians, clinical staff, and administrative staff together spent over 200 hours annually per physician on MIPS-related activities in one study [3]. It doesn't take the patient's social context or level of deprivation into account—in a separate study, that same research group found that physicians caring for more socially disadvantaged patients had lower scores [4]. And size matters—clinicians affiliated with health systems composed of hospitals and multispecialty group practices scored better than their peers in small practices [2]. So, like a batting average, a number on MIPS only tells a very small part of the story. The problems with MIPS would be tolerable if its ratings showed a real difference in outcomes that matter to patients. But they don't. One large study [1] evaluated 3.4 million patients cared for by 80,000 primary care physicians and showed that 19% of physicians with low MIPS scores had composite outcomes performance metrics in the top quintile, while 21% of physicians with high MIPS scores had outcomes in the bottom quintile. This corroborates the findings of our featured article in CORR®, in which Schloemann and colleagues [6] found only a small association between MIPS quality scores for individual physicians and the risk of an unplanned hospital visit after outpatient orthopaedic surgery, and that these visits consisted mostly of trips to the emergency department. To carry the baseball analogy just a bit further, a batting average is less important than a winning record. But this topic really benefits from an expert perspective, and for that reason, we're so happy to have the chance to go deep with Derek Schloemann MD, MPHS, first author of "Are Quality Scores in the Centers for Medicaid and Medicare Services Merit-based Incentive Payment System Associated With Outcomes After Outpatient Orthopaedic Surgery?" Take 5 Interview with Derek T. Schloemann MD, MPHS, first author of "Are Quality Scores in the Centers for Medicaid and Medicare Services Merit-based Incentive Payment System Associated With Outcomes After Outpatient Orthopaedic Surgery?" Paul A. Manner MD, FRCSC:Whenever I hear or see a new acronym, I suffer from MEGO (My Eyes Glaze Over). What's different or novel about MIPS compared to previous attempts at assessing and rewarding quality care? Derek T. Schloemann MD, MPHS: MIPS is the primary component of the legislation that replaced the sustainable growth rate formula (SGR). The SGR, enacted in 1997, involved fee cuts for all physicians when national Medicare spending growth exceeded the target rate. In later years, fee cuts of 20% to 30% had been recommended but were repeatedly postponed. The transition to MIPS creates a value-based purchasing program that includes all specialties. Most orthopaedic surgeons participate in MIPS, which aims to adjust reimbursements through bonuses and penalties to individual clinicians depending on the quality of care. Moreover, it consolidates the features of several separate reforms that preceded it, such as the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBPM), and the Medicare Electronic Health Record (EHR) Incentive program / Meaningful Use program (MU), while adding a fourth dimension of clinical practice improvement. Dr. Manner:One of the unintended consequences of the Patient Protection and Affordable Care Act (Obamacare) was that safety-net hospitals that provided care to sicker patients often were penalized for readmissions, higher lengths of stay, and worse outcomes. Could that be what's going on here? How might we avoid this? Dr. Schloemann: It is possible that clinicians caring for patients with higher levels of complexity may have performed worse in MIPS. This could certainly be the case here, and prior evidence from other specialties would support that argument. CMS has addressed this issue in recent years with the Complex Patient Bonus, which adds bonus points to the MIPS score for clinicians caring for patient populations with a high degree of medical complexity or with high rates of dual-eligibility for Medicare and Medicaid (a marker of patients who are resource-limited). The impact of the Complex Patient Bonus on the clinicians participating in the MIPS program has not yet been fully elucidated. There is considerable opportunity for growth in bettering the risk adjustment approaches that can be used to minimize the unintended effects of the program. Dr. Manner:As part of your conclusion, you recommend that MIPS be "modified to more strongly link reimbursement to risk-adjusted patient outcomes, thereby better-aligning incentives between patients, surgeons, and CMS" [6]. What suggestions might you provide on how to do that? The devil is always in the details. For example, clinicians might simply "upcode" by listing every possible ailment—which seems like gaming the system. Dr. Schloemann: My colleagues and I feel it would be better to use more objective measures that could potentially be drawn from claims data. The current system involves selecting six out of several hundred potential quality measures, which are not specialty-specific. The volume of quality measures and consideration of only a small number for reimbursement adjustments results in both a substantial administrative burden and an incentive to game the system by optimizing reporting strategies rather than by improving patient outcomes. Additionally, current measures require manual entry, which can take time and resources that potentially could be better utilized caring for patients. One example of a meaningful claims-based quality measure specific to surgeons could be the risk-adjusted rates of postoperative unplanned hospital visits, a quality measure that CMS has already linked to facility reimbursement for outpatient surgery in hospital outpatient departments and ambulatory surgery centers. While it would be difficult to remove any incentive to "game the system," we feel that this approach would be fairer than the current one. Dr. Manner:Wishing for those sorts of changes to happen won't make them happen. What would it take to make them happen, and how likely is that result? Dr. Schloemann: The Medicare Payment Advisory Commission (MedPAC) has identified multiple flaws with MIPS. Substantial resources are utilized to meet MIPS reporting requirements, costing an estimated USD 1.3 billion during the first year. In addition, quality assessment is largely through process measures, and each clinician is only scored on six out of several hundred possible measures. This makes scores difficult to interpret and makes comparisons across different clinicians particularly challenging. Recognizing these flaws, MedPAC has called for elimination of the MIPS program and potentially transitioning to a voluntary value program (VVP). The VVP involves payments based on performance on population-based measures, and involves clinicians organizing themselves into groups that would collectively be held responsible for patient outcomes. These major changes would require legislative action and likely further clarification of the policy through the rulemaking process. We aren't aware of any promising efforts to make these major changes. Perhaps this could change following the 2024 elections. Dr. Manner:Finally, if you could start with a blank slate, how would you design a system to reward clinicians who excel while correcting those who need a bit of help? Dr. Schloemann: That's a tough one! While it would be desirable to have a single reform that addresses all the weaknesses of previous reforms, maybe the VVP that MedPAC now recommends would be a step in the right direction. This framework acknowledges that multiple clinicians contribute to the care and outcomes of each patient and would allow for payment adjustment at the level of the group. Each group would be assigned a uniform set of claims- or survey-based population-based measures, and reimbursement adjustments could be made at the group level. These measures also would not involve a significant administrative burden as manual entry would be eliminated. By addressing some of the important shortcomings of the MIPS and previous reforms, we hope that the VVP would advance value-based reimbursement for physicians.