Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York.
Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York.
JAMA. 2020 Sep 8;324(10):975-983. doi: 10.1001/jama.2020.13129.
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.
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.
Physicians in the highest quintile of proportion of dually eligible patients served; physicians in the 3 middle quintiles; and physicians in the lowest quintile.
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.
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).
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.
美国基于绩效的激励支付系统（MIPS）是一项主要的医疗保险基于价值的支付计划，旨在提高质量和降低成本。对于患者的社会风险如何影响医生的表现，知之甚少。
确定在 MIPS 的第一年，患者社会风险与医生评分之间的关系。
设计、地点和参与者：对 2017 年参与 MIPS 的医生进行的横断面研究。
服务的双重合格患者比例最高的五分位医生；中间三个五分位的医生；和最低五分位的医生。
主要结果是 2017 年的综合 MIPS 评分（范围，0-100；分数越高表示表现越好）。根据分数调整支付率为-4%至 4%。
最终样本包括 284544 名医生（76.1%为男性，60.1%有≥20 年的实践经验，11.9%在农村地区，26.8%在医院，24.6%在初级保健）。平均综合 MIPS 评分为 73.3。处于最高风险五分位的医生照顾了 52.0%的双重合格患者；处于中间三个五分位的医生照顾了 21.8%；处于最低风险五分位的医生照顾了 6.6%。在调整医疗复杂性后，处于最高风险五分位的医生（64.7）的平均 MIPS 评分相对中间三个五分位（75.4）和最低五分位（75.9）的医生（最高与中间三个五分位的差异，-10.7[95%CI，-11.0 至-10.4]；最高与最低五分位的差异，-11.2[95%CI，-11.6 至-10.8]；P < .001）的评分较低。这种关系在除精神病学以外的所有专业中都存在。与处于最低风险五分位的医生相比，处于最高风险五分位的医生更有可能在农村地区工作（12.7%比 6.4%；差异，6.3 个百分点[95%CI，6.0 至 6.7]；P < .001），但照顾的 Medicare 受益人数超过 1000 人（9.4%比 17.8%；差异，-8.3 个百分点[95%CI，-8.7 至-8.0]；P < .001）或有超过 20 年的实践经验（56.7%比 70.6%；差异，-13.9 个百分点[95%CI，-14.4 至-13.3]；P < .001）的可能性较小。对于处于最高风险五分位的医生，一些特征与较高的 MIPS 评分相关，包括在更大的团体中执业（平均评分，超过 50 名医生为 82.4，1-5 名医生为 46.1；差异，36.2[95%CI，35.3 至 37.2]；P < .001）和通过替代支付模式报告（平均评分，替代支付模式为 79.5，个人报告为 59.9；差异，19.7[95%CI，18.9 至 20.4]；P < .001）。
在对参与医疗保险 MIPS 计划第一年的医生进行的这项横断面分析中，具有最高比例的 Medicare 和 Medicaid 双重合格患者的医生的 MIPS 评分明显低于其他医生。需要进一步研究以了解医生 MIPS 评分与患者社会风险水平之间差异的根本原因。
