How Does CMS' Merit-based Incentive Payment System Penalize or Reward Orthopaedic Surgeons Caring for Socially...

Area of Science:

• Health Policy and Management
• Value-Based Healthcare
• Orthopaedic Surgery

Background:

• The Merit-based Incentive Payment System (MIPS) is a large value-based payment program in the U.S. designed to adjust physician reimbursement based on performance.
• Concerns exist that MIPS may disadvantage physicians serving socially at-risk patients, leading to the implementation of the Complex Patient Bonus (CPB).
• Evidence is limited regarding MIPS performance, the impact of social risk on scores, and the CPB's effect in orthopaedic surgery.

Purpose of the Study:

• To assess orthopaedic surgeons' MIPS performance, including payment adjustments and bonuses.
• To determine if treating more socially at-risk patients correlates with lower MIPS scores and payment adjustments.
• To evaluate the association of the Complex Patient Bonus (CPB) with MIPS scores and payment adjustments for surgeons serving high-risk populations.

Main Methods:

• Analysis of 2021 national CMS data for orthopaedic surgeons participating in MIPS.
• Dual eligibility for Medicare and Medicaid used as a proxy for patient social risk, with surgeons stratified into quintiles.
• Multivariable regression used to assess the association between social risk, CPB, MIPS scores, and payment adjustments.

Main Results:

• Nearly all (97%) orthopaedic surgeons received a positive MIPS payment adjustment; 0.5% received the maximum penalty.
• Surgeons treating higher proportions of socially at-risk patients achieved higher MIPS scores, particularly with the CPB.
• No significant difference in payment adjustments or exceptional performance bonuses was observed based on patient social risk.

Conclusions:

• A disconnect exists between MIPS performance scores and financial outcomes, especially for surgeons managing socially at-risk patients.
• Current MIPS metrics may not adequately capture or reward the care provided to complex patient populations.
• Future value-based payment models require robust risk adjustment to ensure fairness and gain surgeon buy-in.