New data raise concern about Medicare quality payment program, radiology experts say
New data are raising concern among radiologists and other physicians about how Medicare is administering a critical payment program tied to care value.
In the Merit-based Incentive Payment System, or MIPS, quality measures are typically “topped out” when reporting clinicians consistently achieve high performance. This results in potential scoring “caps” and eventual removal from the list of measures, Neiman Health Policy Institute experts write in Health Affairs Scholar.
However, a new analysis of Medicare data demonstrates that these topped-out designations may not actually reflect universally high performance. In fact, over half of measures reaching this achievement had report rates below 5%, researchers wrote April 12.
“Our findings show that many MIPS quality measures were deemed topped out based on performance reported by a relatively small subset of eligible physicians,” YoonKyung Chung, PhD, principal economic and health services researcher at the Neiman Institute, which is affiliated with the American College of Radiology, said in a statement. “This raises concerns about whether topped-out designations accurately reflect quality performance across the broader clinician population.”
The study utilized CMS Quality Payment Program datasets, linking this information with MIPS benchmark information. Between 2017 and 2023, nearly 644,000 physicians reported performance on measures tied to their medical area of expertise. The study included a total of 37 specialties and 275 MIPS measures of which 49% (or 137) were topped out. Only 11 of these measures were reported by more than half of eligible physicians, the study found. The median reporting rate was about 7% and ranged anywhere from less than 1% for geriatric medicine to 38% for diagnostic radiology and 40% for pathology.
Out of 37 specialties, 70% (or 26) had over half of their measures first topped out by 2023. Radiation oncology (100%), general surgery (94%) and diagnostic radiology (93%) had the highest proportions of maxed-out measures. Similar patterns were seen for topped-out measures that were later capped during the study period, the authors noted. This means the maximum score a physician can earn for that measure is reduced from 10 points down to 7. Doing so limits financial upside for physicians and signals that overall performance is allegedly so high that further gains are not possible. Among 305 specialty-specific measures, half had never been reported by 94% of eligible physicians before being capped. Median reporting rates varied anywhere from less than 1% for infectious disease specialties to nearly 49% in diagnostic radiology.
Neiman Institute experts noted that specialty organizations such as ACR have invested “substantial resources” in developing these quality measures. Their premature removal, despite low reporting rates, limits opportunities for quality improvement. It also discourages maintenance of quality among physicians, with unnecessary subsequent costs to develop new replacement measures.
“When few full-score, specialty-relevant measures are available, it undermines the ability of MIPS to meaningfully compare performance and incentivize improvement in areas most relevant to patient care,” study co-author Lauren P. Nicola, MD, CEO of Triad Radiology Associates, Winston Salem, North Carolina, said in a statement. “Alternative approaches—such as applying topped-out and cap-and-removal policies at the clinician or entity level rather than universally—could preserve incentives for continued quality improvement while maintaining flexibility within the program.”
Another previous Neiman study also found that small imaging groups and individual radiologists face structural disadvantages in MIPS. Given some of these challenges, the American College of Radiology has urged Medicare to add more imaging-related measures in the program.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.