We interviewed leaders of 30 practices that participated in the MIPS program in 2019, i.e., 9 small primary care practices, 6 small general surgery practices, 4 medium primary care practices, 4 medium general surgery practices, and 7 large multispecialty practices (Table 1). No significant differences were observed between respondents and non-respondents (eTable 1). Practices were located in all US census regions. In total, 46.7% of practices reported through a MIPS APM; the mean fee-for-service Medicare share was 21.9%. The analysis resulted in 6 major themes. They are presented along with illustrative quotations in Table 2.
Theme 1: MIPS Is Seen as a Continuation of Prior Value-Based Purchasing Programs—and a Marker of Things to Come
Many participants reported that they saw MIPS as the next phase in the evolution of Medicare VBP programs. In particular, participants reported that the Meaningful Use program had previously motivated practice changes and prepared them for aspects of the MIPS program: “For us, it all started with Meaningful Use and that’s kind of morphed into MIPS. With Meaningful Use, certain things were required or recommended and we worked those into our practice and carried them forward. It’s just kind of second nature now.” Another respondent said: “I think when we first started doing this, there was a lot to do. Now we have our interfaces set up and we have been doing this for three or four years. But the initial setup was tremendous.”
Participants also reported that the decision to invest additional time and resources into MIPS participation was partially influenced by a belief that similar VBP programs will be introduced by both public and private insurance programs in the future: “We slowly realized that it’s not just MIPS, or even Medicare. This stuff is now coming from all insurers and payors…It’s more and more a part of where health care is going.” Another practice leader said reported that “we felt that this was the direction that eventually we’re going to be forced to go anyway.”
Theme 2: MIPS Measures Are More Relevant for Primary Care Practices than for General Surgery or Multispecialty Practices
During interviews with practices of different specialties, many leaders felt that current MIPS measures are more appropriate for primary care practices than other specialties. Leaders of general surgery practices reported that “for surgeons, there are not a lot of measures. We basically choose by what we score the highest on. We don’t really do tobacco counseling, breast cancer screening, flu vaccines.” Another practice leader stated that “being a general surgery practice, we would never do any of these. They are so far from what we can even make work.” The participant suggested that having fewer, more relevant measures would be helpful. Large multispecialty practices also reported challenges identifying measures to report on that seemed relevant to different specialists within their groups: “As a multispecialty group…finding measures that the whole group could meet together was a concern.”
Theme 3: Practice Leaders Held Mixed Perceptions About Whether MIPS Improves Patient Care
Whether MIPS improves patient care was the question about which opinions differed most among participants. In an analysis of transcripts completed by two coders (Y.Q. and E.O.), 3 practices expressed consistently positive views of MIPS; 22 practices expressed intermediate or ambivalent views; and 5 practices expressed consistently negative views (Table 3). Four of the 5 practices with consistently negative views were small practices of 9 or fewer physicians; no other consistent pattern emerged. Some participants suggested that MIPS is beneficial in theory, but the complexity of the program renders it ineffectual and burdensome. Participants who reported MIPS improved care cited greater attention to activities that might otherwise have been neglected—annual wellness visits, chronic disease management, services for hearing-impaired patients—while those who had negative views of the program felt such measures were irrelevant to their practice or required burdensome data collection and reporting activities they were already engaged in.
One participant, emblematic of practice leaders who had negative views of MIPS, said: “MIPS has absolutely hurt. I see no benefit for patient care.” The views of practice leaders with more moderate views were captured by a participant who reported that “the end result—which is keeping patients healthy, closing gaps, keeping people out of hospital—that goal is what internal medicine is all about. But the hoops that we have to jump through are sometimes very onerous.” Some reported that, with time, the potential benefits of MIPS accrue, whereas the initial burdens, related to startup costs of investing in a data collection and reporting infrastructure, decrease: “It feels like MIPS helps patient care. In the beginning, that was hard to see. But I can now see that it’s come full circle. It’s becoming less of a burden—maybe there are less things to do, or maybe we’ve figured it out.”
But even participants who reported that MIPS may have improved patient care felt that the program was burdensome: “I feel like it has improved care but it’s very costly. It takes so much time to gather all that information that you cannot see as many patients.” One participant noted, “my time is a big cost. I would say, $30,000 a year of my salary would probably be attributed to [MIPS] directly”; another reported that expense of participation was equivalent to a “full-time person with benefits—probably like a $50,000 is needed to make this work.”
Theme 4: MIPS Creates Substantial Administrative Burden which is Exacerbated by Frequent Programmatic Changes
Nearly all participants reported substantial administrative burden associated with MIPS participation, and many described yearly changes to the program as a particular source of frustration. These include introduction or removal of quality measures; changes in weighting of MIPS score domains; new requirements and incentives; and uncertainty around the size of rewards and penalties. One participant said that “it seems like CMS can’t leave things the same ever.” Several practices reported that the program’s administrative burden results in physicians seeing fewer patients, which has implications both for patient access and for practice revenue. Finally, some interviewees suggested that MIPS-related burdens create burnout for some physicians: “The docs are frustrated with the extra clicking and form filling out. The price that they are having to pay is burnout. It’s just not rewarding.” They reported that, because of MIPS, some senior physicians have chosen to retire rather than continue working part-time.
Theme 5: MIPS Incentives Are Small Relative to the Effort Needed to Participate in the Program
Many practices reported that MIPS financial incentives were insufficient to justify the level of effort needed to participate in the program. One participant stated that “financially for us it is not at all meaningful. What we received in MIPS payments doesn’t cover the cost and time that we invest.” Other practice leaders expressed similar concerns: “We were close to 100% performance and got a 1.6% positive payment adjustment. You spend a whole bunch of time and do a lot of work, and then you get a tiny adjustment. It’s not really worth it.” A number of practices reported that their decision to participate in MIPS was driven by a desire to avoid financial penalties, not obtain rewards for good performance: “I personally think that what we’re doing is avoiding a penalty. Because we know we will be punished financially if we don’t do everything perfectly.” For some practices, potential penalties were perceived as large and distressing: “Penalties make it unbearable not to participate. The carrot isn’t enticing, but the stick is painful.”
A major cost for many practices was hiring or repurposing staff; the level of investment varied by practice size. Small practices either hired or repurposed 1 additional employee to focus on MIPS (e.g., medical assistant or care manager), or added MIPS-related activities to existing responsibilities of the practice administrator. One administrator said: “Even in a small practice, there’s a need for someone—full time or part time—to manage this component. It is very time consuming for me to do this on top of what I already do.” Medium-sized practices generally hired or repurposed 1 or 2 staff members to focus on MIPS and other quality-reporting programs, while large multispecialty practices often devoted three or more people to such activities.
Another major cost was forgone revenue due to clinician time being spent on quality reporting instead of seeing patients. One small primary care practice reported a 6% decline in patient visits, equivalent to about $200,000 a year. Another practice reported that, prior to MIPS, physicians saw an average of 22 patients per day; after implementation, they saw 16 to 18 patients per day.
Theme 6: External Support for MIPS Participation Can Be Helpful
Many practices reported interacting with external entities to support better MIPS performance. These entities included local hospitals, accountable care organizations, practice transformation networks supported by CMS, and consulting companies such as Aledade. Practices generally found such support helpful, particularly when they were developing data collection and reporting infrastructure early in the program: “We did bring in outside consultants. They ran around with us for a year. They helped us navigate through a lot of very arduous processes with all the extra boxes to collect.”
Several practice leaders reported that Medicare Practice Transformation Networks (PTN) were useful in understanding and participating in MIPS: “There was this program funded program by Medicare that was extremely helpful. Someone would meet with me like five times a year and help just muddle through the issues we were having.” A few larger practices reported feeling that they were in a relatively privileged position with regard to having the time and resources to engage external consultants and perform well in MIPS: “There are obviously some practices that do not have resources we have, or the time to dedicate to this. I can’t imagine not having the time to do adequate research on this stuff. I mean, it’s very complicated to understand and it changes every year.”