Manouchehri Amoli Mahmoud, Cunningham Peter J, Cassel Brian, Carroll Nathan W, Dahman Bassam
Department of Health Policy, School of Public Health, Virginia Commonwealth University, Richmond, Virginia, USA.
Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA.
J Eval Clin Pract. 2025 Aug;31(5):e70217. doi: 10.1111/jep.70217.
Identifying how fraudulent practices affect quality performance metrics is crucial for enhancing healthcare delivery and maintaining the integrity of the Medicare system.
To examine the association between fraud and abuse perpetrator providers (FAPs) and their performance on quality metrics within the Merit-Based Incentive Payment System (MIPS) under the Medicare Access and CHIP Reauthorization Act (MACRA).
A retrospective observational study using exact matching and propensity score matching to balance comparison groups.
Analysis of Medicare Quality Payment Program (QPP) data from 2017 to 2021.
A total of 12,364 physician-year observations, including 1300 provider-year level FAPs identified between 2020 and 2023 and 11,064 matched non-FAPs.
Provider status as fraud and abuse perpetrators based on inclusion in the List of Excluded Individuals and Entities from the Office of Inspector General.
MIPS scores across key categories: Final score, Quality score, Promoting Interoperability (PI) score, Improvement Activities (IA) score, and Cost score.
FAPs scored significantly lower than non-FAPs in Final score, Quality score, PI score, and IA score (all p < 0.05). The negative impact of FAP status was more pronounced among individual practitioners, while FAPs participating in Advanced Alternative Payment Models exhibited higher scores on certain metrics. No significant differences were observed in Cost scores between FAPs and non-FAPs.
Fraudulent practices are associated with lower performance on quality-related metrics under MACRA's MIPS framework, particularly among individual practitioners. While lower quality scores align with expectations for providers committing fraud, the absence of significant differences in Cost scores highlights potential shortcomings in the MIPS scoring system, suggesting that cost metrics may not be sufficiently sensitive to fraudulent practices. These findings underscore the need for continuous refinement of both quality and cost measures to enhance the integrity and effectiveness of healthcare delivery.
识别欺诈行为如何影响质量绩效指标对于改善医疗服务提供和维护医疗保险系统的完整性至关重要。
研究根据《医疗保险准入与儿童健康保险计划再授权法案》（MACRA）中的基于绩效的激励支付系统（MIPS），欺诈与滥用行为实施者提供者（FAPs）与其在质量指标上的表现之间的关联。
一项回顾性观察研究，使用精确匹配和倾向得分匹配来平衡比较组。
对2017年至2021年医疗保险质量支付计划（QPP）数据进行分析。
总共12364个医生年度观察数据，包括2020年至2023年期间确定的1300个提供者年度水平的FAPs和11064个匹配的非FAPs。
根据被监察长办公室列入排除个人和实体名单，提供者作为欺诈和滥用行为实施者的状态。
关键类别的MIPS分数：最终分数、质量分数、促进互操作性（PI）分数、改进活动（IA）分数和成本分数。
FAPs在最终分数、质量分数、PI分数和IA分数方面的得分显著低于非FAPs（所有p<0.05）。FAP状态的负面影响在个体从业者中更为明显，而参与高级替代支付模式的FAPs在某些指标上得分较高。FAPs和非FAPs在成本分数方面未观察到显著差异。
在MACRA的MIPS框架下，欺诈行为与质量相关指标的较低表现相关，尤其是在个体从业者中。虽然较低的质量分数符合对实施欺诈的提供者的预期，但成本分数没有显著差异凸显了MIPS评分系统的潜在缺陷，表明成本指标可能对欺诈行为不够敏感。这些发现强调需要持续完善质量和成本衡量标准，以提高医疗服务提供的完整性和有效性。
