Psychiatrists had significantly lower performance scores, received more penalties, and earned fewer bonuses in the 2020 Medicare Merit-Based Incentive Payment System (MIPS) compared to other outpatient physicians, according to a study published in JAMA Health Forum.

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Under MIPS, CMS monitors provider performance across four categories—quality, promoting interoperability, improvement activities, and cost—to determine their future Medicare reimbursement rates. Each provider receives a score, which coincides with either a negative, neutral, or positive payment adjustment.

In 2020, 5 percent of Medicare reimbursement for providers was tied to their 2018 MIPS performance. CMS predicted that by the end of 2022, MIPS payment penalties and bonuses would increase to up to 9 percent of provider Medicare reimbursement.

CMS designed MIPS to assess performance for a wide range of outpatient providers. Still, the value-based payment system may not be the perfect fit to evaluate care quality for certain specialty physicians—such as psychiatrists—due to the lack of specialty-specific measures.

To understand how psychiatrist MIPS performance scores and payment adjustments compared to other outpatient physicians, researchers gathered MIPS participant information from the CMS Provider Data Catalog and the National Downloadable File between January 1, 2018, and December 31, 2020. The study sample consisted of primary care physicians, medical specialists, obstetrician-gynecologists, and psychiatrists.

Out of over 205,000 physicians, 9,356 were psychiatrists and 196,306 fell under the other specialties. Psychiatrists were less likely to participate in MIPS in 2018 compared to other outpatient physicians, researchers found.

The mean MIPS performance score for all physicians was 89.4, with 3.1 percent receiving negative payment adjustments, 96 percent receiving positive payment adjustments, and 88.4 percent earning bonus payments.

When comparing psychiatrists to other physicians, psychiatrists saw lower scores and more negative payment adjustments. The mean MIPS performance score was 84 for psychiatrists and 89.7 for other physicians. Similarly, 6.1 percent of psychiatrists received negative payment adjustments, while only 2.9 percent of other physicians did.

Additionally, other physicians were more likely to receive positive payment adjustments (96.3 percent) compared to psychiatrists (92.6 percent). Physicians were also less likely to earn bonus payments (82 percent) than other physicians (88.7 percent).

Physicians had lower adjusted means for all four MIPS measures compared to other physicians. The most significant differences were in the quality and promoting interoperability scores.

Physician performance varied across the top 20 individual MIPS performance measures.

Psychiatrists had similar or lower reporting rates and scores for technology-dependent MIPS measures compared to other psychiatrists. In particular, psychiatrists were significantly less likely to report participating in a health information exchange.

For measures that were not dependent on technology, psychiatrists reported more frequently on most measures but received lower mean performance scores on half of the measures, including documentation of current medications and breast cancer screening. However, psychiatrists had higher reporting rates and better scores for measures relevant to psychiatry, such as depression screening and follow-up.

MIPS includes 25 mental and behavioral health specialty measures in the program. Less than 2 percent of psychiatrists reported 13 of these measures, while none of the psychiatrists reported seven of the measures.

“Our findings imply that psychiatrists may not be as well prepared as other outpatient physicians for the reporting and performance requirements of the MIPS program and may experience financial penalties as a result,” researchers wrote.

Psychiatrists are currently less likely to accept Medicare compared to other physicians. Their poor performance in MIPS may further disincentivize them from treating Medicare patients, leading to higher costs for patients and greater barriers to accessing mental healthcare, the study suggested.

“Our findings also raise additional questions about the relevance and appropriateness of the MIPS program for performance assessment of specialists,” researchers said. “Ideally, each specialty would be judged on measures of greatest relevance to the patients treated by that specialty.”

Therefore, CMS should evaluate whether MIPS performance measures accurately assess psychiatrist performance. Additionally, policymakers should consider creating more specialty-specific measures to avoid significant Medicare reimbursement cuts for psychiatrists.

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