Kidney Medicine | 2021
Early Nephrologist Performance in the Merit-Based Incentive Payment System: Both Reassurance and Reason for Concern
Abstract
of the Sustainable Growth Rate (SGR) formula, which imposed strict caps on physician payments but had been ineffective due to annual postponements. While replacing the SGR with MACRA eliminated the looming threat of large SGR payment cuts to physicians, it represented a shift in physician reimbursement toward value-based payment. The vast majority of Medicare physician providers are now required to participate in 1 of 2 MACRA tracks, the MeritBased Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (AAPM). Under these tracks, MACRA seeks to reward high-quality cost-efficient clinicians with reimbursement bonuses while imposing financial penalties on lower-quality more expensive clinicians. Most patients with kidney failure have Medicare coverage, making virtually all practicing US nephrologists subject to MACRA’s payment incentives. Most nephrologists, 91% in 2017, are not part of an AAPM and are therefore enrolled in MIPS. This includes nephrologists reporting as individual clinicians, clinician groups, or as a part of an Alternative Payment Model (APM) that does not satisfy the stringent risk requirements necessary to qualify as an AAPM. MIPS evaluates physicians annually by combining their performance in the following 4 distinct measure categories into a single “final score”: Quality, Promoting Interoperability, Improvement Activities, and Cost. Because MIPS evaluates physician performance across all specialties and primary care disciplines, some specialties may fare better than others and clinician, patient, and geographic characteristics may influence performance under MIPS. For instance, clinicians who care for patients at high social risk have been found to perform worse in MIPS, whereas clinicians affiliated with large health systems may perform better. Nephrologists care for medically complex patients in a wide range of settings and commonly care for patient populations at high social risk. If performance measures included in MIPS do not fully account for the complexity and range of settings in which nephrologists provide care, performance in MIPS could be affected.