A national survey of physicians elicits beliefs regarding how the Merit-based Incentive Payment System domains drive value.
Objectives: To understand physician perspectives about drivers of value within the 4 domains—quality, improvement activities, promoting interoperability, and cost—of the Merit-based Incentive Payment System (MIPS).
Study Design: National web-based physician survey.
Methods: Those surveyed who believed that MIPS domain activities would improve value were asked about mechanisms—quality (structural quality, process quality, or outcome quality), patient experience, and/or cost—they believe would drive those improvements.
Results: Of 1431 physicians, 51% responded. Most believed that value would be improved by activities in the 4 MIPS domains of quality (55%), improvement activities (70%), promoting interoperability (54%), and cost (71%). Process quality was the most frequently selected driver in the quality (77%), improvement activities (70%), and promoting interoperability (70%) domains.
Conclusions: Among physicians who believed that MIPS domain activities would improve value, most believed that would occur predominantly through process improvement activities rather than other forms of quality, patient experience, or cost containment.
Am J Accountable Care. 2021;9(1):4-8
Implemented in 2017, the Medicare Merit-based Incentive Payment System (MIPS) represents the largest pay-for-performance program to date in the United States.1 Through MIPS, Medicare engages more than 1 million clinicians2 caring for Medicare beneficiaries around the country and uses financial incentives to encourage these clinicians to deliver higher-quality and more cost-conscious (ie, higher-value) care.
In the MIPS program, clinicians are evaluated in 4 domains: quality (eg, reporting and performance on clinical quality measures), improvement activities, promoting interoperability (eg, using health information technology to improve care), and cost. Performance in these 4 domains ultimately dictates how clinicians are affected by MIPS, with higher-performing clinicians receiving overall increases in professional payment rates from Medicare and lower-performing clinicians receiving overall decreases in payment rates.
Physicians must be engaged stakeholders for MIPS to succeed, and many physicians believe that core activities in the 4 domains can improve value (ie, improve quality while maintaining or lowering costs, or lower costs while maintaining or improving quality).3 However, value is inherently multifaceted, given its relationship to the underlying mechanisms of quality, cost, and patient experience. In turn, quality itself is multifaceted. Based on the framework articulated by Donabedian,4 quality can be defined in 3 categories: structural (ie, the setting or context of care), process (ie, the actions taken to provide care), and outcome (improvement in care outcomes).
Consequently, understanding physician perspectives about how MIPS domain activities specifically improve value (eg, through improvements in quality, patient experience, or cost efficiency) can illuminate beliefs that policy makers can emphasize in order to engage physicians in MIPS. This is critical insight, given the calls to reform the program and improve the experience of participating clinicians.5,6
Our analysis uses data from a nationwide web-based survey implemented in collaboration with the American College of Physicians and fielded among 1431 internal medicine physicians between March 22 and May 7, 2017. The study methodology has been described in detail previously.3
Survey responses were stratified by respondents’ age (< 50 years vs ≥ 50 years), gender (male vs female), individual compensation (cost incentive vs other [noncost] incentive vs no incentive), specialty (generalist [primary care, geriatrics, hospital medicine] vs specialist), and regional level of physician reimbursement (using zip code, respondents were designated to hospital referral regions and determined to be in “high-spending” [mean Medicare reimbursement greater than or equal to national mean] or “low-spending” [mean Medicare reimbursement less than national mean] regions).7
We focused our analysis on responses to 4 questions (Table 14), the results of which have not been previously published. Each of these key questions focused on a MIPS domain and was directed to respondents who indicated in a separate, preceding question that activities in that domain improved value. In each question, respondents who believed that value would be improved through activities in a given domain were asked which mechanisms—quality, patient experience, and/or cost—explained the improvement in value (ie, how the activities improved value). For instance, respondents who reported in a preceding question the belief that quality domain activities improved value were asked the following question (1 of the 4 key questions in our analysis): If physician efforts to report and perform well on clinical quality measures somewhat or significantly improve the value of patient care, which of the following do they impact?
Answer choices consisted of (1) setting, context, or infrastructure in which care is delivered; (2) actions that physicians take in the process of providing care; (3) patient outcomes; (4) costs of care; and (5) patient experience. Answer choices 1 through 3 were adapted from the framework articulated by Donabedian4 described previously. We categorized answer choices 1, 2, and 3 as structural quality, process quality, and outcome quality, respectively.
Survey responses were described using percentages. Chi-square tests and t tests were used to compare categorical and continuous variables, respectively. Significance was determined with 2-tailed tests at the 0.05 α level. Analyses were performed using SAS version 9.4 (SAS Institute). This study was determined exempt by the University of Pennsylvania Institutional Review Board.
Among 1431 physicians, 51% (726) responded. Respondents were 51% male with a median age of 48 years, and 71% were general internists (primary care, geriatrics, or hospital medicine). Compared with internal medicine physicians nationally, respondents were younger and more likely to be female.8,9 Approximately half reported that quality (52%) or productivity (51%) affected their compensation. Compared with nonrespondents, respondents were more likely to be male (51% vs 42%; P < .001) and older (mean age, 50 years vs 45 years; P < .001). Forty-three percent of respondents practiced in low-spending regions; 57% practiced in high-spending regions. Most respondents believed that value would be improved by activities in the 4 domains: quality (55%; n = 399), improvement activities (70%; n = 503), promoting interoperability (54%; n = 385), and cost (71%; n = 509). Ninety percent of respondents thought that value would be improved by activities in at least 1 of the domains, and 32% thought that value would be improved by activities in all 4 of the domains.
Physician perspectives regarding whether value would be improved by activities in each domain varied by age, gender, and compensation incentives but did not vary by clinical specialty type (generalists vs specialists) or regional spending (Table 2). In particular, older respondents (50 years and older) were less likely than younger respondents to believe that value was driven through the improvement activities (65% vs 74%; P = .008), promoting interoperability (45% vs 61%; P < .0001), or cost (65% vs 77%; P = .0021) domains. However, there was no difference in age groups regarding beliefs about the impact of the quality domain on value (51% among older respondents vs 59% among younger respondents; P = .099). Female respondents were more likely than male respondents to believe that value was driven through the quality (61% vs 53%; P = .024), improvement activities (78% vs 68%; P = .012), and promoting interoperability (62% vs 49%; P = .0008) domains but not through the cost domain (74% vs 71%; P = .23). Compensation incentives—cost vs other noncost (ie, incentives related to quality, patient satisfaction, or productivity) vs none—were associated with different beliefs about whether the quality domain (57% vs 60% vs 47%, respectively; P = .03) or improvement activities domain (65% vs 76% vs 63%; P = .0087) drove value.
Of respondents who believed that domain activities would improve value, process quality was the most frequently selected mechanism in the quality (77%; n = 306), improvement activities (70%; n = 354), and promoting interoperability (70%; n = 270) domains (Table 1). Costs of care was the most frequently selected mechanism (86%) among the 509 respondents who reported the belief that cost domain activities would improve value. As mechanisms, patient experience and structural quality were selected by fewer than half of respondents across the 4 MIPS domains.
Within the quality domain, 246 (62%) and 306 (77%) physicians believed that patient outcomes and process quality, respectively, drove value, whereas 182 (46%) believed both mechanisms did. Similarly, 335 (67%) and 354 (70%) physicians believed that patient outcomes and process quality, respectively, drove quality in the improvement activities domain, with 237 (47%) believing both did. In the promoting interoperability domain, 270 (70%) physicians responded that process quality drove value, whereas only 206 (54%) believed that patient outcomes did so and 154 (40%) believed that both did so. In the cost domain, approximately half of physicians thought that patient outcomes and process quality drove value (253 [50%] and 266 [52%], respectively), whereas fewer (158 [31%]) believed that both mechanisms did so.
This analysis provides insight into physician perspectives about how MIPS can improve value. The results demonstrate that when physicians believe that MIPS domain activities positively impact value, they do so predominantly through process quality rather than other forms of quality, patient experience, or cost containment. These findings pose several implications.
First, they raise caution about the policy decision to shift the focus of MIPS away from process quality (eg, moving incentives or performance evaluation toward other, nonquality domain activities), as Medicare has begun to do. In all 4 domains, more respondents believed that their efforts to improve value through reporting and performance on measures in MIPS domains were more likely to affect processes of care than outcomes. One potential implication is that retaining emphasis on process improvement alongside clinical outcomes and other forms of quality may be important for maintaining physician engagement in MIPS.
Engagement has been a key policy opportunity area for the program, particularly given early concerns raised by the complexity and uncertainty about MIPS performance.5 Going forward, policy makers have an opportunity to address these issues in the development of MIPS Value Pathways10—new approaches that seek to use tailored sets of performance measures to increase MIPS engagement among clinicians from different specialties. In particular, policy makers could intentionally ensure that salient process quality measures are selected and emphasized for each Value Pathway. This focus on quality would also be consistent with evaluations of other pay-for-performance programs, which have been associated with improvement in process measures but not outcome measures.11
Second, our findings highlight the importance of defining and building consensus about the meaning of “value” in payment reform. To date, many payment reforms have equated value to cost reduction and stable quality. Although this is one appropriate definition, others exist. In particular, an alternative approach—which is codified in federal statute and recognized by Medicare—conceives of value as improved quality with stable cost.12 This definition aligns with our finding that physicians believed improving quality would be a major driver of value in the context of MIPS.
Third, nearly half of physicians who believed that MIPS activities improve value noted improvements in patient experience as a key mechanism. This finding aligns with the priority that Medicare has placed on increasing patient experience and engagement in value-based payment reforms—for example, through other novel advanced alternative payment models such as direct contracting.13 Given Medicare’s goal to better align MIPS and alternative payment models,10 as well as the fact that patient experience and engagement are not currently incorporated into MIPS, there is an opportunity to better incorporate them into the program going forward. MIPS Value Pathways provide another potential way for policy makers to further emphasize patient experience: Although they prioritize patient-centered outcomes, policy makers could design them to directly call out patient experience measures.
Fourth, our findings highlight potential for varying levels of engagement in different subgroups of physicians. For example, in multiple domains, female physicians and those who were younger were more likely to believe that domain activities contribute to value of care. Medicare could capture these perspectives by ensuring that MIPS Value Pathways engage a wide range of clinicians, including individuals from these subgroups, in the development process.
Our study has limitations. First, the generalizability of our results is limited by response rate, as well as the potential for more familiarity with MIPS and more favorable views regarding health care reform among respondents vs nonrespondents.3 Second, our survey evaluated physician perspectives in the first year of MIPS, which may differ from those in subsequent years. Third, survey questions measured beliefs about clinical decisions rather than behavior. Fourth, our results reflect overall physician perspectives, but future work should evaluate perspectives stratified by clinician (eg, MIPS performance) and practice (eg, type, size) characteristics.
Among physicians who believed that MIPS domain activities would improve value, most believed that would occur predominantly through process improvement activities rather than other forms of quality, patient experience, or cost containment. Our results spotlight potential opportunities for policy makers to engage physicians as key stakeholders to improve and ultimately achieve the goals of MIPS.
Author Affiliations: Department of Medicine, University of Washington School of Medicine (LMM, LZ, JML), Seattle, WA; Value & Systems Science Lab (LMM, LZ, JML), Seattle, WA; Corporal Michael J. Crescenz VA Medical Center (ASN), Philadelphia, PA; Department of Medical Ethics and Health Policy, Perelman School of Medicine (ASN), and Leonard Davis Institute of Health Economics (ASN, JML), University of Pennsylvania, Philadelphia, PA.
Source of Funding: None.
Author Disclosures: Dr Navathe reports grants from Hawaii Medical Service Association, Anthem Public Policy Institute, Commonwealth Fund, Oscar Health, Cigna Corporation, Robert Wood Johnson Foundation, Donaghue Foundation, Pennsylvania Department of Health, Ochsner Health System, United Healthcare, Blue Cross Blue Shield of NC, and Blue Shield of CA; personal fees from Navvis Healthcare, Agathos Inc, Navahealth, YNHHSC/CORE, Maine Health Accountable Care Organization, Maine Department of Health and Human Services, National University Health System - Singapore, Ministry of Health - Singapore, Elsevier Press, Medicare Payment Advisory Commission, Cleveland Clinic, and The Analysis Group; equity from Embedded Healthcare and Navahealth; and other from Integrated Services Inc outside the submitted work. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (LMM, ASN, JML); acquisition of data (ASN, LZ, JML); analysis and interpretation of data (LMM,ASN, LZ, JML); drafting of the manuscript (LMM, ASN); critical revision of the manuscript for important intellectual content (LMM, ASN, JML); statistical analysis (LMM, ASN, LZ); obtaining funding (ASN); administrative, technical, or logistic support (LMM, ASN); and supervision (ASN, JML).
Send Correspondence to: Leah M. Marcotte, MD, Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98105. Email: email@example.com.
1. Participation options overview. CMS. Accessed January 3, 2021. https://qpp.cms.gov/mips/overview
2. CMS. 2017 Quality Payment Program reporting experience. Primary Care Collaborative. Accessed January 3, 2021. https://www.pcpcc.org/sites/default/files/resources/2017%20QPP%20Experience%20Report.pdf
3. Liao JM, Shea JA, Weissman A, Navathe AS. Physician perspectives in year 1 of MACRA and its Merit-based Payment System: a national survey. Health Aff (Millwood). 2018;37(7):1079-1086. doi:10.1377/hlthaff.2017.1485
4. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44(3, pt 2):166-206. doi:10.2307/3348969
5. Liao JM, Navathe AS. Implications of MIPS scoring on clinician engagement in value-based payments. Health Affairs. October 30, 2018. Accessed January 3, 2021. https://www.healthaffairs.org/do/10.1377/hblog20181029.492700/full/
6. Liao JM, Chen A, Navathe AS. The real opportunities of MIPS payment adjustments. Health Affairs. October 29, 2018. Accessed January 3, 2021. https://www.healthaffairs.org/do/10.1377/hblog20181026.940799/full/
7. Medicare reimbursements. Dartmouth Atlas Project. Accessed January 3, 2021. https://www.dartmouthatlas.org/interactive-apps/medicare-reimbursements/
8. Active physicians by sex and specialty, 2017. American Association of Medical Colleges. Accessed January 3, 2021. https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-sex-and-specialty-2017
9. Active physicians by age and specialty, 2017. American Association of Medical Colleges. Accessed January 3, 2021. https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-age-and-specialty-2017
10. MIPS Value Pathways (MVPs). CMS. Accessed January 3, 2021. https://qpp.cms.gov/mips/mips-value-pathways
11. Mendelson A, Kondo K, Damberg C, et al. The effects of pay-for-performance programs on health, health care use, and processes of care: a systematic review. Ann Intern Med. 2017;166(5):341-353. doi:10.7326/M16-1881
12. CMMI model certifications. CMS. Updated January 8, 2021. Accessed January 3, 2021. https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/CMMI-Model-Certifications.html
13. Primary Care First Model Options. CMS. Updated December 1, 2020. Accessed January 3, 2021. https://innovation.cms.gov/initiatives/primary-care-first-model-options/