Gill Vikram S, Lin Eugenia, Holle Alejandro, Haglin Jack M, Clarke Henry D
Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA.
Mayo Clinic Alix School of Medicine, Phoenix, AZ, USA.
Clin Orthop Relat Res. 2025 May 1;483(5):820-828. doi: 10.1097/CORR.0000000000003350. Epub 2024 Dec 20.
Value-based care payment and delivery models such as the recently implemented Merit-based Incentive Payment System (MIPS) aim to both provide better care for patients and reduce costs of care. Gender disparities across orthopaedic surgery, encompassing reimbursement, industry payments, referrals, and patient perception, have been thoroughly studied over the years, with numerous disparities identified. However, differences in MIPS performance based on orthopaedic surgeon gender have not been comprehensively evaluated.
QUESTIONS/PURPOSES: After controlling for potentially confounding variables such as experience, geography, group size, and Medicare beneficiary characteristics, does MIPS performance differ between men and women orthopaedic surgeons?
The Medicare Physician and Other Practitioners and the Physician Compare databases were queried for years 2017, the first year MIPS was incorporated, and 2021, the most recent year with MIPS data published, to identify all physicians with a self-reported specialty of orthopaedic surgery. Together, these databases include all physicians who submitted at least 11 Medicare claims each year. Physician gender, US census region, years in practice, group practice size, billing practices, and patient demographic characteristics were collected for each surgeon. The MIPS Performance database was used to extract an overall MIPS performance score for each surgeon for each year. Payment adjustments, which are determined based on overall MIPS performance score, were derived for each surgeon based on the thresholds published by the Centers for Medicare & Medicaid Services. Payment adjustments include a negative adjustment, neutral adjustment, positive adjustment, or exceptional performance bonus and are associated with different thresholds each year. Statistical differences based on surgeon gender were assessed utilizing chi-square tests for categorical data, Student t-test for parametric continuous data, and Wilcoxon signed-rank test for nonparametric continuous data. Univariable and multivariable analyses were performed to analyze the relationship between surgeon gender and MIPS performance.
After controlling for other patient and surgeon variables, woman gender was associated with a slightly increased MIPS performance score in 2021 (β 1.5 [95% confidence interval (CI) 0.02 to 3.00]; p = 0.047). However, this finding was statistically fragile, with the lower bound 95% CI being very close to the line of no difference. No association between surgeon gender and MIPS performance score was found in 2017 (β 2.2 [95% CI -0.5 to 4.9]; p = 0.11). Additionally, no relationship was found between gender and receiving either an exceptional performance MIPS bonus or a MIPS penalty in either year.
Women orthopaedic surgeons scored slightly higher on the MIPS in 2021, after controlling for surgeon and patient variables, despite providing care for a higher percentage of dual Medicare-Medicaid eligible patients and more medically complex patients. However, this finding was statistically fragile, with a small effect size, a 95% CI close to 0, and no consistent association in MIPS performance in 2017. Additionally, with no differences in MIPS performance bonuses or penalties, the clinical monetary impact of this difference may be minimal.
The observed association between surgeon gender and MIPS performance scores in 2021, with women orthopaedic surgeons achieving slightly higher scores, raises interesting questions about potential differences in practice behaviors, communication styles, care quality, or other unmeasured variables. These findings may reflect true differences in how care is delivered or documented as scored by the MIPS. However, given the small effect size, statistical fragility, and inconsistency across years, there is a chance that this finding may be spurious. That being so, future research should aim to validate or refute these findings by examining a broader range of variables including documentation practices, practice behaviors, institutional differences, potential systemic biases in scoring methodologies, and patient outcomes. Understanding whether these differences are true is important to ensure that performance metrics like MIPS accurately and equitably reflect care quality.
基于价值的医疗支付和服务模式，如最近实施的基于绩效的激励支付系统（MIPS），旨在为患者提供更好的医疗服务并降低医疗成本。多年来，人们对骨科手术中存在的性别差异，包括报销、行业支付、转诊和患者认知等方面，进行了深入研究，并发现了许多差异。然而，基于骨科医生性别的MIPS表现差异尚未得到全面评估。
问题/目的：在控制了经验、地理位置、团队规模和医疗保险受益人的特征等潜在混杂变量后，男性和女性骨科医生的MIPS表现是否存在差异？
查询医疗保险医生及其他从业者数据库和医生比较数据库，获取2017年（MIPS纳入的第一年）和2021年（有MIPS数据公布的最近一年）的数据，以识别所有自我报告为骨科手术专业的医生。这两个数据库共同涵盖了每年至少提交11份医疗保险索赔的所有医生。收集了每位外科医生的性别、美国人口普查地区、执业年限、团队执业规模、计费方式以及患者人口统计学特征。使用MIPS绩效数据库提取每位外科医生每年的总体MIPS绩效得分。根据医疗保险和医疗补助服务中心公布的阈值，为每位外科医生得出基于总体MIPS绩效得分的支付调整。支付调整包括负调整、中性调整、正调整或卓越绩效奖金，并且每年与不同的阈值相关联。利用卡方检验评估分类数据中基于外科医生性别的统计差异，使用学生t检验评估参数连续数据的差异，使用威尔科克森符号秩检验评估非参数连续数据的差异。进行单变量和多变量分析以分析外科医生性别与MIPS表现之间的关系。
在控制了其他患者和外科医生变量后，2021年女性与MIPS绩效得分略有增加相关（β 1.5 [95%置信区间（CI）0.02至3.00]；p = 0.047）。然而，这一发现的统计学意义不稳固，95% CI的下限非常接近无差异线。2017年未发现外科医生性别与MIPS绩效得分之间存在关联（β 2.2 [95% CI -0.5至4.9]；p = 0.11）。此外，在这两年中，性别与获得卓越绩效MIPS奖金或MIPS处罚之间均未发现关联。
在控制了外科医生和患者变量后，2021年女性骨科医生在MIPS上的得分略高，尽管她们为同时符合医疗保险和医疗补助资格的患者以及病情更复杂的患者提供了更高比例的护理。然而，这一发现的统计学意义不稳固，效应量小，95% CI接近0，且2017年MIPS表现无一致关联。此外，由于MIPS绩效奖金或处罚没有差异，这种差异在临床货币方面的影响可能很小。
2021年观察到的外科医生性别与MIPS绩效得分之间的关联，即女性骨科医生得分略高，引发了关于实践行为、沟通方式、护理质量或其他未测量变量潜在差异的有趣问题。这些发现可能反映了MIPS评分中护理提供或记录方式的真实差异。然而，鉴于效应量小、统计学意义不稳固以及多年来的不一致性，这一发现有可能是虚假的。即便如此，未来的研究应旨在通过检查更广泛的变量来验证或反驳这些发现，这些变量包括记录方式、实践行为、机构差异评分方法中潜在的系统偏差以及患者结局。了解这些差异是否真实对于确保像MIPS这样的绩效指标准确、公平地反映护理质量很重要。
