From the Chair of the Commission on Economics
Gregory N. Nicola, MD, FACR

In her song “Anti-Hero,” Taylor Swift sings, “It’s me, hi, I’m the problem, it’s me.” It’s a very catchy song, which CMS should adopt as the anthem for the MIPS program.

MIPS stands for the Merit-based Incentive Payment System. It’s the fee-for-service (FFS) component of the Quality Payment Program (QPP). The QPP is part of the Medicare Access and CHIP Reauthorization Act (MACRA), which was passed in 2015 with bipartisan support. The QPP reformed the Medicare Part B physician payment system. It has two main tracks: MIPS and alternative payment models (APMs). MIPS is the major pathway for many in radiology, especially those in private practice.

The intent of MIPS is noble. There were concerns that a straight FFS system rewards physicians based on the volume and intensity of care delivered, not the relevance or impact of that care. MIPS was intended to promote the value of care delivery, not just volume.

With MIPS, Medicare providers continue to be reimbursed on an FFS basis, but the amount of the payment varies based on a provider’s cumulative score, from 0 to 100, on a series of performance measures. Annually, CMS establishes a “performance threshold,” such that providers or groups that score above the threshold get a positive adjustment to their Medicare FFS payments and those that score below get a penalty. For budget neutrality purposes, the penalties fund the bonuses (meaning the losers pay the winners).

Ironically, there is concern that MIPS may be reducing value. The program is burdensome to physicians and costly to administer. A study showed that the annual mean cost to practices participating in MIPS was almost $13,000 per physician and the time required was about 200 hours per physician annually. As evidence of the program’s unevenness, it is possible for a diagnostic radiology practice to score perfectly on the performance measures that CMS makes freely available to specialties and still be penalized for underperformance.

Annually, CMS establishes a “performance threshold,” such that providers or groups that score above the threshold get a positive adjustment to their Medicare FFS payments and those that score below get a penalty.

The impacts on radiology result primarily from a lack of relevant measures and point caps on those measures. In 2023, of the eight clinical quality measures that CMS freely offers diagnostic radiology, six are capped at seven points (versus the standard maximum of 10). For comparison, CMS offers family medicine 41 uncapped quality measures. Of the two uncapped measures CMS offers radiology, neither has a benchmark, limiting their value. In 2024, the diagnostic radiology measure set will only include six measures. Five of those measures are capped at seven points and one does not have a published benchmark. The family medicine set will offer 63 measures in 2024.

Even beyond the inequities among specialties, there are inherent and meaningful deficiencies in the program. For example, the performance threshold is based (by statute) on previous scores. Earlier this year, CMS proposed to elevate the threshold from 75 to 82 points in 2024, making it even harder for radiology practices to avoid a penalty. Benchmarking from past performance assumes an equivalency between past and present, which does not exist. For example, in past years, bonus points were available, helping practices achieve higher scores and avoid penalties. Those bonus points have been removed, but the scores they helped achieve are being used to establish expectations for future performance.

Others have also noted the program’s failures. This summer, Congress held a hearing on MACRA, and MIPS was singled out for its shortcomings. Congressional members from both parties noted that the program is complex and expensive. Calling for the elimination of MIPS, J. Michael McWilliams, MD, PhD, a professor of healthcare policy at Harvard Medical School, stated, “I do not recall a more uniformly and resoundingly critiqued payment policy in my career.” Previously, in a Report to Congress, the Medicare Payment Advisory Commission (MedPAC) noted fundamental problems with MIPS and called for its elimination.

The ACR is aware of the challenges of MIPS for radiologists and is working to address them. In its most recent comment letter to CMS, the College made several suggestions to improve the program. To its credit, CMS took some of the suggestions, including a decision to leave the performance threshold at 75 points for 2024. While this is an important win for our specialty, serious concerns with the program remain.

To help radiology practices with MIPS and their quality improvement efforts, the ACR offers practices the opportunity to submit data on a range of measures through its National Radiology Data Registry (NRDR™), a Qualified Clinical Data Registry. The NRDR, which is discounted for ACR members, offers radiologists additional measures to report on, hopefully helping them improve their performance and their Medicare payments.

The MIPS program is complex, expensive and burdensome. Instead of helping radiologists improve the value of care, the program encourages gamesmanship as practices try to avoid a penalty. For the 2023 performance year, CMS is allowing practices to apply for an exemption due to “extreme and uncontrollable circumstances.” However, this flexibility is unlikely to be widely available in upcoming years.

While the recently issued final rule from CMS on MIPS in 2024 is an improvement, there are still profound deficiencies and inequities in the program. Hopefully, with future improvements in performance reporting, we can get to a point where Taylor is inspired to write a new song for CMS: “It’s me, hi, I’m the problem solver, it’s me.” Well, I’m sure Taylor will make it a lot catchier.