Related Experiment Video
Updated: Dec 9, 2025
Inverse Probability of Treatment Weighting Propensity Score using the Military Health System Data Repository and National Death Index
Published on: January 8, 2020
Adjustment For Social Risk Factors Does Not Meaningfully Affect Performance On Medicare's MIPS Clinician Cost
Alexander T Sandhu1, Jay Bhattacharya2, Joyce Lam3
1Alexander T. Sandhu (ats114@stanford.edu) is an instructor in the Department of Medicine at Stanford University, in Stanford, California. He is also a health policy consultant at Acumen, LLC, in Burlingame, California.
Abstract:
Medicare's Merit-based Incentive Payment System (MIPS) includes episode-based cost measures that evaluate Medicare expenditures for specific conditions and procedures. These measures compare clinicians' cost performance and, along with other MIPS category scores, determine Medicare Part B clinician payment adjustments. The measures do not include risk adjustment for social risk factors. We found that adjusting for individual and community social risk did not have a meaningful impact on clinicians' cost measure performance. Across eight cost measures, 1.4 percent of clinician groups, on average, had an absolute change in their cost measure performance percentile of 10 percent or more (range, 0.4-3.4 percent). Prior analyses have generally found higher health care costs for patients with increased social risk. MIPS episode-based cost measures are distinct from previous cost measures because they only include costs related to the specific condition being evaluated. This unique approach may explain why costs were similar for patients with high and low social risk before any risk adjustment. MIPS episode-based cost measures do not appear to penalize clinicians who primarily care for patients with increased social risk.
Insights
Medicare
Area of Science:
- Health economics
- Health services research
Background:
- Medicare's Merit-based Incentive Payment System (MIPS) uses episode-based cost measures to assess clinician performance.
- These measures influence Medicare Part B payments but lack social risk factor adjustment.
- Previous studies indicated higher healthcare costs associated with increased social risk.
Purpose of the Study:
- To determine if adjusting for social risk factors impacts clinician performance on MIPS episode-based cost measures.
- To evaluate if MIPS cost measures unfairly penalize clinicians serving high-social-risk populations.
Main Methods:
- Analysis of Medicare's episode-based cost measures.
- Inclusion of individual and community social risk factors in the analysis.
- Assessment of changes in clinician cost measure performance percentiles before and after risk adjustment.
Main Results:
- Adjusting for social risk factors had a minimal impact on clinician cost measure performance.
- On average, only 1.4% of clinician groups experienced a significant performance change (≥10 percentile points).
- MIPS episode-based cost measures showed similar costs for patients with high and low social risk, suggesting no inherent penalty.
Conclusions:
- Medicare's episode-based cost measures appear robust to social risk factor adjustment.
- These measures do not seem to disadvantage clinicians caring for patients with higher social risk.
- The specific design of MIPS cost measures, focusing on condition-related costs, may explain these findings.
Related Concept Videos
01:08Effect of Hepatic Disease on Pharmacokinetics: Dose Adjustments Due to Hepatic Impairment
01:23Types of Biopharmaceutical Studies: Controlled and Non-Controlled Approaches
Non-controlled studies, commonly employed for initial exploration, lack a control group, rendering them susceptible to biases and external influences. In contrast,...
01:29Bias in Epidemiological Studies
01:15Methods of Documentation VI: Case Management Model
For example, a patient with a chronic...
01:20Mismatch Repair
The Mutator Protein Family Plays a Key Role in DNA Mismatch Repair
The human genome has more than 3 billion base pairs of DNA per cell. Prior to cell division, that vast amount of genetic...
01:36Mismatch Repair