Think about the last time you dictated a follow-up radiology report and nothing, or at least not much, had changed. You could almost copy and paste the old report, and the results would sound the same. This column seems to be that way for me, as I compare the recently released 2018 Quality Payment Program (QPP) results with those from 2017. While I cannot quite copy and paste 2017’s results (which I described in my February 2019 column at acr.org/QPP-Year1), relatively little has changed. Scores remain high, and bonuses remain low. Yet, there are some early trends worth highlighting (see table 1).
Most of the professionals captured by these performance numbers are physicians — but not all, as other professionals, such as podiatrists and dentists, are included. Collectively, this broad group is referred to as Eligible Professionals (EPs).
MICRO-TREND 1: Overall performance remains quite high.
Performance scores increased from 89 in 2017 to 99.63 in 2018. As a result, the percentage of physicians in both the bonus pool and the exceptional performance pool increased to 84% in 2018, compared with 71% in 2017. At the same time, there were fewer physicians who received a negative adjustment — only 2%.
Going forward, by definition, EPs cannot do much better than 99.63 out of 100. Year 2018 was considered the second transitional year by CMS; therefore, 2018’s scores may be a peak. Contributing to this could be other categories, such as Cost and Advancing Care Information, which will increase in weight and relative impact.
MICRO-TREND 2: Bonus payments remain quite low.
Positive adjustments (or bonuses) remain low. The maximum bonus in 2018 decreased to 1.68% from 1.88% in 2017. In broad terms, the Merit-Based Incentive Payment System (MIPS) is a budget-neutral system in which penalties pay for bonuses. With only 2% of EPs receiving the maximal penalty of 5%, there simply is not much money to move to the bonus pool. The scaling factor adjusts bonuses, and when the scaling factor is less than 1, the bonuses become quite small.
Going forward, as scores lower and the performance threshold increases, more EPs may receive a penalty. This could yield greater positive adjustments for those who score favorably. If the scaling factor becomes greater than 1, bonus payments could reach double digits, which could be more motivating than the current modest bonus amounts.
MICRO-TREND 3: Small practices are doing better.
Large practices again did better than small practices, scoring 92 compared with 66 for small practices. But that gap narrowed by 72% compared with 2017. Contributing to this improvement were extra points and accommodations provided to small practices by the 2018 MIPS scoring rules, such as an additional 5 points onto the final score.
In the future, criticisms that the program is difficult for small practices remain, perhaps increasing consolidation to larger practices with greater resources. As small practices do better, this pressure may lessen. And as a result, small, independent practices will be able to not only survive but thrive.
Year 2018 was considered the second transitional year by CMS; therefore, 2018’s scores may be a peak.
MICRO-TREND 4: Physicians are moving from MIPS to APMs.
The number of EPs in MIPS decreased by 100,000, while the number in Advanced Alternative Payment Models (APMs), referred to as Qualifying APM Participants (QPs) — increased by 83,000. It is not entirely clear whether these are the same physicians moving from MIPS to APMs, but the absolute shift of 8–10% supports a positive trend in APM uptake. To maintain this trend, CMS will need to increase its APM offerings, particularly to specialists. The availability of an adequate number of measures under MIPS remains problematic and may necessitate a greater move to APMs.1
In conclusion, physicians should be pleased with their high scores. The optics of scoring 100 are undoubtedly favorable. But the small bonuses are only a marginal reward for this effort. The return on investment is not obvious. The movement of EPs from MIPS to APMs is slow but increasing. New programs, such as the MIPS Value Pathways, may provide additional options for all EPs. Looking ahead, EPs should not assume that the same amount of effort as that in 2018 will suffice.