Intended and Unintended Consequences of the Merit-Based Incentive Payments System Program: Early Evidence

根据《医疗保险准入和儿童健康保险计划再授权法》(2015)，该中心 对于Medicare和Medicaid服务(CMS)，建立了基于功绩的奖励支付系统计划 (MIPS)。该计划结束了长期实行的按服务收费补偿临床医生的制度，并 改变了医疗保险制度，奖励更高质量和更低成本的医疗保健。在MIPS下，临床医生 需要报告四个领域的业绩数据：护理质量、参与改进活动、 有意义地使用电子健康记录，并降低成本。CMS对每个域进行加权以计算复合值 性能分数。该计划于2017年生效，并公开公布了成绩得分。 从2019年开始，临床医生开始获得高达其联邦医疗保险B部分4%的支付调整 根据2017年取得的绩效分数支付。调整可以向上或向下， 最大调整幅度将在2020年提高到5%，从2022年起增加到9%。 MIPS生效四年来，几乎没有证据表明它对预期目标(质量和 护理费用)。此外，与CMS推出的许多早期基于价值的计划类似，MIPS具有 对激励战略应对措施表示关切，但对护理质量几乎没有影响。例如，要 避免减少支付，MIPS临床医生可能会通过参考以下方法战略性地降低患者风险 高危患者，可能导致健康结果的差异。到目前为止，还没有研究检验过 MIPS的潜在意外影响。 为了填补这些知识空白，我们建议检查预期的和潜在的意外不利因素 MIPS使用该计划前三年(2017-2019年)数据的后果。这项研究将使用 全国有代表性的随机抽样参加MIPS的临床医生和他们的患者来自50个州和 哥伦比亚特区。我们将合并几个提供者级别的CMS公共报告数据和患者级别的数据 联邦医疗保险声称数据将参与提供者与他们所属的患者联系起来。我们的具体目标是(1) 通过以下方式检查提供者和患者特征是否存在系统性差异 绩效得分和(2)评估绩效改进与以下各项相关的程度 医疗保健结果和患者概况的变化。 这将是第一次检查预期的(改善的医疗结果)和非预期的影响的研究 (患者风险概况的变化)。MIPS头三年的调查结果将向CMS通报 该程序的发展和改进，并作为未来研究MIPS性能的基础 规模更大，而且在以后的几年里。

Under the Medicare Access and Children's Health Insurance Program Reauthorization Act (2015), the Center for Medicare & Medicaid Services (CMS) established the Merit-Based Incentive Payment System Program (MIPS). The program ended the long-standing system that reimbursed clinicians on a fee-for-service basis and shifted Medicare to a system that rewards higher-quality and lower-cost care. Under MIPS, clinicians are required to report data on performance in four domains: quality of care, participation in improvement activities, meaningful use of electronic health records, and cost. CMS weighs each domain to calculate a Composite Performance Score. The program became effective in 2017, with performance scores publicly reported. Starting in 2019, clinicians began receiving payment adjustments of up to 4% of their Medicare Part B payments based on the performance scores achieved in 2017. The adjustment can be upward or downward, and the maximum adjustment is set to increase to 5% in 2020 and 9% from 2022 onward. Four years since MIPS took effect, there is little evidence for its impact on the intended targets (quality and cost of care). Furthermore, similar to many earlier value-based programs that CMS introduced, MIPS has raised concerns about incentivizing strategic responses with little impact on quality of care. For example, to avoid payment reductions, MIPS clinicians may strategically lower their patient risk profiles by referring out high-risk patients, potentially leading to disparities in health outcomes. No research to date has examined the potential unintended effect of MIPS. To fill these knowledge gaps, we propose to examine both desired and potential unintended adverse consequences of MIPS using data from the first three years of the program (2017-2019). This study will use a nationally-representative random sample of MIPS-participating clinicians and their patients from 50 states and the District of Columbia. We will merge several provider-level CMS public reporting data with patient-level Medicare claims data to link participating providers with their attributed patients. Our specific aims are to (1) examine if there are systematic differences in the characteristics of providers and patient profiles by performance scores and (2) evaluate the extent to which performance improvements are associated with changes in healthcare outcomes and patient profiles. This will be the first study to examine the intended (improved healthcare outcome) and unintended effects (changes in patient risk profile) of MIPS. Findings from the first three years of MIPS will inform CMS on the evolution and refinement of the program and serve as the basis for future research on MIPS performance at a larger scale and over later years.