A survey of internal medicine physicians has revealed low levels of familiarity with the Merit-based Incentive Payment System (MIPS), with some respondents also believing that MIPS requirements could lead to unintended consequences.
The research, from University of Pennsylvania scholars, and published in the July issue of Health Affairs, set out to explore if physicians believed that their efforts in four focus areas identified in the survey would ultimately improve the value of care. The researchers attest that this survey, conducted in 2017, is the first since the implementation of MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) among a large physician sample (684 participants that completed the survey), maintained by the American College of Physicians (ACP).
The survey consisted of three sections. In the first, several questions used a four-point scale to evaluate respondents’ beliefs about the degree to which performance in the four focus areas (reporting and performing well on clinical quality measures; initiating or participating in clinical practice improvement activities; controlling patients’ use of resources; and implementing and using electronic health records, or EHRs) is within physicians’ control and should be tied to their compensation. These areas correspond to the four MIPS domains but were not identified as such in the survey, to avoid biasing the responses because of physicians’ views of MIPS, noted the researchers.
Respondents were also asked about their willingness to make changes in their clinical decisions and actions in each of the focus areas to improve value. Then, in the second section of the survey, respondents were first asked to report their level of familiarity with MACRA requirements. They were then informed that MIPS “financially rewards or penalizes physicians based on participation and performance” in the domains of quality, resource use, advancing care information, and clinical practice improvement activities and were asked to indicate, using a five-point scale, how they believed MIPS as a policy would ultimately affect the value of patient care.
Physicians were next asked whether new incentives under MIPS would lead to a series of behaviors that could represent unintended consequences. In the third section of the survey, respondents were informed that under MIPS, “physician payments will be adjusted based on a composite score derived from performance” in the four domains.
What the Research Found
When informed that those areas represented the four MIPS domains, the majority of respondents remained positive about the likely impact on value. However, expectations varied by physicians’ characteristics and sense of control over the desired outcomes, and many respondents believed that unintended consequences could occur.
For instance, more than half of the respondents reported “some” or “a great deal” of willingness to change their behavior for the sake of value with respect to each of the following four focus areas: reporting and performing well on clinical quality measures (53 percent), initiating or participating in clinical practice improvement activities (59 percent), controlling patients’ use of resources (58 percent), and implementing and using electronic health records, or EHRs (58 percent). Comparatively, smaller proportions reported believing that at least some compensation should be tied to these focus areas (35 to 41 percent) and that physicians have at least some control over these areas (36 to 45 percent).
This pattern also existed across different compensation incentives. Physicians reported greater willingness to change behavior for the sake of value, compared to their belief that compensation should be tied to focus areas or that physicians have control over them.
What’s more, most respondents reported believing that physicians’ efforts in the four focus areas would “somewhat or significantly” improve the value of patient care. However, some physicians expressed the belief that such efforts would either reduce value or neither improve nor reduce it. In particular, nearly half felt that implementing and using EHRs (46 percent) and reporting and performing well on clinical quality measures (45 percent) would either not affect or negatively affect value.
The research also found that 60 percent of physicians reported being not at all or only slightly familiar with MACRA and its requirements, and only 8 percent reported being very familiar. Once respondents were informed about the four MIPS domains, nearly equal proportions reported believing that MIPS would improve (38 percent) or have no impact (41 percent) on the value of care, while a smaller share (21 percent) believed that it would reduce the value of care.
According to the researchers, in conclusion, “These findings indicate an immediate need to continue educating physicians about MIPS requirements—particularly physicians not affected by cost, quality, or both types of incentives and those who might not receive information through professional societies such as the ACP. Policymakers also should consider targeting educational messages based on physicians’ reimbursement environments.”
The researchers continued, “Because every policy has the potential for unintended consequences, policymakers should also take note of the widespread belief among respondents that new incentives under MIPS might prompt physicians to ‘game the system.’”
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