key: cord-0068469-kslnalzq
authors: Tummalapalli, Sri Lekha; Mendu, Mallika L.; Struthers, Sarah A.; White, David L.; Bieber, Scott D.; Weiner, Daniel E.; Ibrahim, Said A.
title: Nephrologist Performance in the Merit-Based Incentive Payment System
date: 2021-07-21
journal: Kidney Med
DOI: 10.1016/j.xkme.2021.06.006
sha: e8ae09c6ff8eb4699d5af139dc5dbe33156aaab2
doc_id: 68469
cord_uid: kslnalzq

RATIONALE & OBJECTIVE: The Merit-Based Incentive Payment System (MIPS) is the largest quality payment program administered by the Centers for Medicare & Medicaid Services. Little is known about predictors of nephrologist performance in MIPS. STUDY DESIGN: Cross-sectional analysis. SETTING & PARTICIPANTS: Nephrologists participating in MIPS in performance year 2018. PREDICTORS: Nephrologist characteristics: (1) participation type (individual, group, or MIPS alternative payment model [APM]), (2) practice size, (3) practice setting (rural, Health Professional Shortage Area [HPSA], or hospital based), and (4) geography (Census Division). OUTCOMES: MIPS Final, Quality, Promoting Interoperability, Improvement Activities, and Cost scores. Using published consensus ratings, we also examined the validity of MIPS Quality measures selected by nephrologists. ANALYTICAL APPROACH: Unadjusted and multivariable-adjusted linear regression models assessing the associations between nephrologist characteristics and MIPS Final scores. RESULTS: Among 6,117 nephrologists participating in MIPS in 2018, the median MIPS Final score was 100 (interquartile range, 94-100). In multivariable-adjusted analyses, MIPS APM participation was associated with a 12.5-point (95% CI, 10.6-14.4) higher score compared with individual participation. Nephrologists in large (355-4,294 members) and medium (15-354 members) practices scored higher than those in small practices (1-14 members). In analyses adjusted for practice size, practice setting, and geography, among individual and group participants, HPSA nephrologists scored 1.9 (95% CI, −3.6 to −0.1) points lower than non-HPSA nephrologists, and hospital-based nephrologists scored 6.0 (95% CI, −8.3 to −3.7) points lower than non–hospital-based nephrologists. The most frequently reported quality measures by individual and group participants had medium to high validity and were relevant to nephrology care, whereas MIPS APM measures had little relevance to nephrology. LIMITATIONS: Lack of adjustment for patient characteristics. CONCLUSIONS: MIPS APM participation, larger practice size, non-HPSA setting, and non–hospital-based setting were associated with higher MIPS scores among nephrologists. Our results inform strategies to improve MIPS program design and generate meaningful distinctions between practices that will drive improvements in care.

Results: Among 6,117 nephrologists participating in MIPS in 2018, the median MIPS Final score was 100 (interquartile range, 94-100). In multivariableadjusted analyses, MIPS APM participation was associated with a 12.5-point (95% CI, 10. 6-14.4) higher score compared with individual participation. Nephrologists in large (355-4,294 members) and medium (15-354 members) practices scored higher than those in small practices (1-14 members) . In analyses adjusted for practice size, practice setting, and geography, among individual and group participants, HPSA nephrologists scored 1.9 (95% CI, −3.6 to −0.1) points lower than non-HPSA nephrologists, and hospital-based nephrologists scored 6.0 (95% CI, −8.3 to −3.7) points lower than non-hospitalbased nephrologists. The most frequently reported quality measures by individual and group participants had medium to high validity and were relevant to nephrology care, whereas MIPS APM measures had little relevance to nephrology.

Limitations: Lack of adjustment for patient characteristics.

Conclusions: MIPS APM participation, larger practice size, non-HPSA setting, and non-hospitalbased setting were associated with higher MIPS scores among nephrologists. Our results inform strategies to improve MIPS program design and generate meaningful distinctions between practices that will drive improvements in care.

T he Merit-Based Incentive Payment System (MIPS) is the largest quality payment program administered by the Centers for Medicare & Medicaid Services (CMS), with 874,515 clinicians participating in 2018. 1 MIPS is a mandatory pay-for-performance program in which eligible clinicians report their performance in 4 categories of measures: Quality, Promoting Interoperability, Improvement Activities, and Cost. Participating clinicians are assigned a Final score that is tied to a financial bonus or penalty. MIPS is part of federal efforts in the United States to incentivize value-based care that is both high quality and cost-efficient. 2 Although MIPS program design has been described previously, nephrologist performance in MIPS has not been reported. 3, 4 Given significant quality-of-care gaps in nephrology, including inadequate hypertension control, 5 suboptimal use of guideline-directed medical therapies, [6] [7] [8] and delays in modality education and access planning, 9 large-scale population health strategies for kidney disease are urgently needed, and value-based programs such as MIPS may play an important role if designed effectively. 10 Previous analyses have examined physician characteristics associated with MIPS performance across specialties, but not among nephrologists specifically. One analysis found that MIPS alternative payment model (APM) participation, larger practice size, and multispecialty practices were associated with higher MIPS scores. 11 In another study, clinician affiliation with a health system through common ownership or joint management was associated with higher MIPS scores. 12 Understanding nephrologist characteristics associated with higher MIPS performance could inform strategies to invest in lower performing practices in future program iterations.

In recent years, a key concern about MIPS is whether quality measures used in the program are valid and relevant. The American College of Physicians deemed that 63% of internal medicine measures were not valid or had uncertain validity due to lack of evidence, unclear attribution to the reporting physician, and other criteria. 13 Our prior work assessing nephrology quality measures showed similar results: only half the nephrology measures were rated as highly valid and many were based on outdated evidence, were not attributable to nephrology care, and lacked appropriate definitions. 14 Given the magnitude of the MIPS program and ongoing quality-of-care gaps in nephrology, it is critical to characterize the performance of nephrologists in MIPS. In this study, we assessed the association of nephrologist participation type, practice size, practice setting, and geography with MIPS performance in performance year 2018. We hypothesized that nephrologists practicing in larger practices would have higher MIPS scores due to greater resources to support high-quality care, consistent with evidence from physicians across other specialties. 11 Given prior concerns about the lack of chronic kidney disease-specific performance measures, 14 we also examined the most frequently selected MIPS measures by nephrologists to characterize their validity and relevance to nephrology care.

Our data source was the CMS 2018 Quality Payment Program Experience Report Public Use File. 15 The Public Use File contains clinician-level data on specialty, MIPS eligibility and exclusion, participation type, practice characteristics, MIPS scores, and payment adjustments. Each clinician is given 5 scores: a Quality score, Promoting Interoperability score, Improvement Activities score, Cost score, and Final score. The Quality Payment Program was legislatively mandated by the Medicare Access and CHIP Reauthorization Act of 2015 and consists of 2 tracks: Advanced APMs and MIPS. 16, 17 Physicians, advanced practice providers (eg, nurse practitioners and physician assistants), and other advanced clinicians such as nurse anesthetists are required to participate in MIPS if they are enrolled in Medicare and exceed a low-volume threshold. Participants in Advanced APMs, payment models that incorporate quality performance and 2-sided financial risk, such as the Medicare Shared Savings Program (Tracks 2 and 3) and End-Stage Renal Disease Seamless Care Organizations with 2-sided risk, are exempt from MIPS if they exceed specific payment and patient thresholds. 18 Nonexempt clinicians can report to MIPS through 3 participation types: (1) as an individual, (2) part of a group practice, or (3) part of a MIPS APM. MIPS APM clinicians are part of APMs, such as the Medicare Shared Savings Program (Track 1), that are distinct from Advanced APMs exempt from MIPS. 19 Patients (beneficiaries) are attributed to clinicians by CMS. Clinicians report measure performance for each patient to CMS through multiple methods, including the CMS Web Interface, electronic health records, registries, Qualified Clinical Data Registries, attestation, or Medicare Part B claims. Data for Taxpayer Identification Numbers/National Provider Identifier with fewer than 11 beneficiaries were suppressed administratively.

Our study population included nephrologists participating in MIPS in performance year 2018. We excluded nephrologists who experienced extreme hardship (eg, Federal Emergency Management Agency-designated major disaster), nephrologists with 100 or fewer Medicare Part B patient-facing encounters (defined as "non-patient-facing" by CMS), and nonreporting (defined as "non-participants" by CMS, no reported data with a Final score of zero), as designated by CMS ( Fig S1) . Nurse practitioners and physician assistants were not included in analyses.

Our predictors included participation type, practice size, practice setting, and geography. Participation type was classified as individual, group, or MIPS APM. 18, 19 Practice size, defined as the number of clinicians associated with the taxpayer identification number, was classified into tertiles (tertile 1, 1-14 clinicians; tertile 2, 15-354; and tertile 3, 355-4,294). Practice setting included: (1) rural versus nonrural, (2) Health Professional Shortage Area (HPSA) versus non-HPSA, and (3) hospital based versus non-hospital based, according to CMS special status designations. 20 Geography was classified into census division and state, based on the location of the clinician's billing practice.

Our primary outcome was nephrologist-level MIPS performance scores, including Final scores and scores by category: Quality (50% of Final score in 2018), Promoting Interoperability (25% for individuals and groups, 30% for PLAIN-LANGUAGE SUMMARY The Merit-Based Incentive Program (MIPS) is the nation's largest pay-for-performance program, incentivizing high-quality cost-efficient care. Understanding nephrologist performance in MIPS may inform efforts to improve care for patients with chronic kidney disease and other nephrology conditions. In this study, we examined how performance in the MIPS program differed by nephrologist participation type, practice size, practice setting, and geography. We found that MIPS alternative payment model (APM) participation, larger practice size, non-Health Professional Shortage Area setting, and non-hospital-based setting were associated with higher MIPS scores among nephrologists in performance year 2018. Our results inform strategies to improve MIPS program design and generate meaningful distinctions between practices that will drive improvements in care.

MIPS APM), Improvement Activities (15% for individuals and groups, 20% for MIPS APM), and Cost (10% for individuals and groups, 0% for MIPS APM Each Quality measure received a score between 3 and 10 points based on historical benchmark performance of the measure among all clinicians, including non-nephrologists. 21 Benchmarks differ based on measure submission type (eg, electronic health records, Qualified Clinical Data Registries, and claims). In contrast, most MIPS APM participants were required to report a designated set of 15 measures using the CMS Web Interface and were compared with separate APM benchmarks. Clinicians received Quality bonus points if they reported electronically or submitted additional outcome measures, patient experience measures, or other high-priority measures beyond the requirements. 21 Improvement points (capped at 10%) were added to the Quality score based on the percent improvement in the Quality performance category from the previous year.

For the Promoting Interoperability performance category, clinicians were required to report on 1 of 2 base measures sets depending on their certified electronic health record edition. Clinicians could also select from additional Promoting Interoperability performance and bonus measures.

For the Improvement Activities performance category, individual and group clinicians reported on 2 to 4 Improvement Activities measures with a total of 113 Improvement Activities to select from in 2018. MIPS APM participants received credit for Improvement Activities required by their respective models and were therefore exempt from reporting additional Improvement Activities measures. The cost performance category included 2 claims-based measures in 2018: 1) Medicare Spending per Beneficiary, which captures costs of an inpatient stay through 30 days postdischarge; and (2) Total Per Capita Costs, which measures beneficiary Medicare Parts A and B spending.

Scores from each of the 4 categories are added to calculate the MIPS Final score, ranging from 0 to 100. Final scores are compared with a MIPS performance threshold to determine the payment adjustment amount applied to Medicare reimbursements in payment year 2020, which could be positive (0% to 1.68%), neutral, or negative (−5.0% to −0.01%). Full scoring methodology is reported in the 2018 MIPS Scoring Guide. 21 Additional key outcomes of interest included a binary variable of achieving the maximum payment adjustment and scores on specific Quality measures. As descriptive outcomes, we determined the top 10 most frequently selected measures by nephrologists in the Quality, Promoting Interoperability, and Improvement Activities categories. For Quality measures, we classified measures as high, medium, and low validity, according to our prior work. 14 

We first calculated the median and interquartile range (IQR) of nephrologist-level Final, Quality, Promoting Interoperability, Improvement Activities, and Cost scores, and the percentage of nephrologists achieving the maximum payment adjustment, overall and stratified by participation type, practice size, practice setting, and Census Division (Table 1 ; Fig S2) . Differences in MIPS scores by nephrologist characteristics were assessed using Wilcoxon rank sum tests. Differences in achieving maximum payment adjustment were assessed using χ 2 tests (for binary predictors) or unadjusted logistic regression (for nominal or ordinal variables).

We then assessed the association of nephrologist characteristics with MIPS Final scores, using separate unadjusted linear regression models for participation type, practice size, practice setting, and Census Division (Fig  1) . 22 Because of statistically significant interactions between participation type and practice size, we stratified multivariable-adjusted analyses by 2 categories of participation type: (1) individual or group and (2) MIPS APM. We performed multivariable-adjusted linear regression to assess the association of nephrologist characteristics with MIPS Final scores, adjusting for practice size, practice setting, and Census Division (Tables 2 and S1). All analyses were at the nephrologist level. We calculated variance inflation factors that did not indicate multicollinearity of the predictors. Residuals plotted against fitted values were consistent with linearity assumptions.

We then reported the top 10 Quality, Promoting Interoperability, and Improvement Activities measures selected by nephrologists (Tables 3 and S2 ). We finally mapped the state-level variation of MIPS Final scores and achieving the maximum payment adjustment among nephrologists ( Fig S3) . Data were fully deidentified and publicly available. Analyses were performed using Stata/ IC, version 15.1 (StataCorp), and R, version 4.0.2, statistical software (R Core Team).

A total of 7,120 nephrologists participated in MIPS in 2018. We excluded nephrologists who reported extreme hardship (222) and those who were non-patient-facing (464), nonreporting (310), or located in US Territories 

Nephrologists' MIPS Final scores were a median of 100 (IQR, 94-100; Table 1 ). MIPS Final, Quality, Promoting Interoperability, and Improvement Activities scores were skewed toward the maximum score (Fig S2) . A total of 3,185 (52%) nephrologists achieved the maximum Final score; 2,767 (45%), the maximum Quality score; 4,288 (70%), the maximum Promoting Interoperability score; and 5,819 (95%), the maximum Improvement Activities score, whereas 192 (3%) nephrologists had the maximum Cost score. A total of 5,893 (97%) nephrologists received Quality bonus points.

Regarding payment adjustments, 17 (0.3%) nephrologists received a negative payment adjustment, 12 (0.2%) received a no (neutral) payment adjustment, and the remaining 6,088 (99.5%) received a positive payment adjustment. A total of 5,522 (90%) nephrologists met CMS's designation of "exceptional" (Final score between 70 and 100) and received a positive payment adjustment ranging from 0.20% to 1.68%, with 3,213 (53%) nephrologists achieving the maximum payment adjustment of 1.68% (Table 1) .

In unadjusted analyses, compared with nephrologists participating in MIPS as individuals, group participants and MIPS APM participants had higher scores (Fig 1) . MIPS APM participants were significantly more likely to receive a maximum payment adjustment (80% of MIPS APM vs 43% of individuals vs 37% of group participants). All scores (Final, Quality, Promoting Interoperability, Improvement Activities, and Cost) were higher for nephrologists in larger size practices in unadjusted analyses (Table 1 ; Fig 1) , and larger practices were more likely to receive the maximum payment adjustment. Rural, HPSA, and hospitalbased settings were associated with lower MIPS Final scores in unadjusted analyses (Fig 1) .

In multivariable-adjusted analyses accounting for participation type and practice size interactions, MIPS APM participation was associated with a 12.5 (95% CI, 10.6-14.4) point higher score compared with individual participants (Table S1 ). Among individual and group participants, HPSA nephrologists scored 1.9 (95% CI, −3.6 to −0.1) points lower than non-HPSA nephrologists, and hospitalbased nephrologists scored 6.0 (95% CI, −8.3 to −3.7) points lower than non-hospital-based nephrologists, in analyses adjusted for practice size, practice setting, and geography (Table 2) . Among MIPS APM participants, rural, HPSA, or hospital-based status was not associated with differences in MIPS Final scores in adjusted analyses. MIPS scores in all domains were variable across geographies (Table 1 ; Fig S3) . Among individual and group participants, nephrologists in the Middle Atlantic and West South Central Census Divisions had lower MIPS Final scores compared with those in New England in adjusted analyses ( Table 2) . (Fig S4) . Compared with individual or group participants, nephrologists reporting as part of a MIPS APM had higher Quality measure scores for vaccination, controlling high blood pressure, and use of aspirin or antiplatelets, whereas scores for body mass index screening and follow-up did not differ by participation type (Fig 2) .

Most Promoting Interoperability measures reported by individuals and group participants spanned topics of patient electronic access, health information exchange, and public health reporting (Table S2 ). Improvement Activities measures spanned a range of topics including access to care, patient engagement, medication management, use of decision support, patient experience, and chronic care management.

In our analysis of national MIPS data from the 2018 performance year, 7,120 nephrologists participated in MIPS, representing~75% of US nephrologists focused on patient care. 23 Scores across the Quality, Promoting Interoperability, and Improvement Activities MIPS domains were very high among nephrologists. Half the participants attained the highest possible Final score, and 99.5% received a positive payment adjustment. MIPS APM participation, larger practice size, non-HPSA setting, and non-hospital-based setting were associated with higher MIPS scores among nephrologists. Nephrologists participating in MIPS APMs had the highest scores despite MIPS APM Quality measures having little relevance to nephrology care. Our results provide the first evidence of MIPS performance in nephrology, with implications for nephrology practices, measure developers, and policy makers. Our results are concordant with prior analyses of MIPS performance across specialties showing that MIPS APM participation and larger practice size were associated with higher MIPS scores. 11, 12 Higher MIPS scores among MIPS APMs and large practices is multifactorial. First, scoring methodology differences benefit MIPS APM participants. In 2018, MIPS APM participants were evaluated on an APM scoring standard and compared with different benchmarks than individual or group participants. 21 Second, MIPS APM participants report on a greater number of measures, which creates more opportunities to gain bonus points in the program. 21 Third, MIPS APM participants and large practices have greater resources to devote to MIPS reporting, which may result in "teaching to the test" behavior to maximize scores. 24, 25 Last, there is evidence that higher resourced settings are associated with higher quality care, potentially due to differences in physician quality, 26 improved care coordination, [27] [28] [29] [30] and investments in health information technology. 31 CMS has taken steps to address concerns about MIPS APM program structure: the APM scoring standard has been eliminated for 2021 and data submission will be the same across participation types, improving comparability of quality measure scores.

One major critique of MIPS has been that self-selection of measures limits reliable performance comparability and ultimately contributes to inequity across practices. 9 Furthermore, self-selection raises concerns about "gaming" the system by choosing measures with easier to attain high scores. We found that the selection of measures was fragmented across more than 100 Quality and Improvement Activities measures. Reassuringly, among the top 10 Quality measures selected by individual and group participants, most had medium to high validity according to our prior work: 5 of the top 10 measures were rated with high validity; 3, with medium validity; and 2 were not rated. 14 Notably, Quality measures reported by MIPS APM nephrologists were heavily focused on primary care. CMS should modify MIPS APM participation further so that their newly created APM Performance Pathway does not attribute primary care measures such as breast and colorectal cancer screening to nephrologists.

Several factors contribute to the widespread perfect or near-perfect MIPS scores among nephrologists. First, the MIPS scoring methodology is structured with multiple opportunities to attain the highest Final score, such as bonus points and improvement scoring. Notably, high Final scores were not a result of individual measure scores being "topped out" (Fig S4) . For example, the mean Quality score on the most frequently reported measure, MIPS 236: Controlling High Blood Pressure, was 7.4 (scores range from 3-10 for those reporting), which may be reasonable based on hypertension control rates from the National Health and Nutrition Examination Survey. 5 There is a discrepancy between near-perfect MIPS scores among nephrologists and known quality of care gaps in chronic kidney disease and hypertension care, including low chronic kidney disease awareness, 32 suboptimal use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and statins, [6] [7] [8] and 80% of incident patients with kidney failure starting with a catheter, 9 indicating that MIPS Final scores are not reflective of the actual quality of nephrology care being provided. This was particularly evident for MIPS APM nephrologists, who had the highest scores and maximum payment adjustments, but whose scores were driven primarily by non--nephrology-related quality measures. Hence, near-perfect MIPS scores provide an inaccurate picture of nephrology care, which may stifle efforts to achieve better population health for patients with kidney disease. Furthermore, universally near-perfect scores hinders the ability of payors and providers to distinguish between high-performing and low-performing clinicians and practices and for patients to make comparisons on public reporting websites such as www.medicare.gov/care-compare. In recent years, MIPS has come under greater scrutiny, with the Medicare Payment Advisory Commission recommending to eliminate MIPS. 33, 34 Our results point to several concrete policy recommendations that CMS should consider in reforming the MIPS program. First, CMS should change MIPS scoring methodology to provide greater differentiation between high-performing and low-performing clinicians. Although high scores may have been initially intended to encourage MIPS participation, MIPS Final scores continue to be "topped out," which does an injustice to clinicians and patients by imposing substantial reporting burden and costs without meaningfully distinguishing performance. Importantly, we believe that this greater variability in scores should be used for assessment but not be tied directly to payment adjustments before other fundamental changes to the program are made because financial rewards are likely to further benefit highly resourced clinicians. CMS's increased weighting of the cost category in subsequent participation years may help achieve greater differentiation between practices.

Second, moving to fewer valid measures that are less burdensome and costly to collect may narrow measured performance gaps between lower and higher resourced settings. 24 Surveys of practices indicate that reporting performance measures requires nearly 800 hours of administrative time, equivalent to $40,000 per physician per year, costing the health care system tens of billions of dollars annually. 35 The vast number of measures (eg, 149 for quality) limits comparability across practices and opens opportunities for gaming. Creating a standardized core set of valid, relevant, specialty-(or condition-) specific measures would simplify the program and engender fair comparisons. In 2022, CMS intends to implement a revised iteration of the program called MIPS Value Pathways that seeks to streamline measure selection and create measure overlap between MIPS and Advanced APMs, such as the Kidney Care Choices voluntary models. The top 10 frequently reported Quality measures selected by individual and group nephrologists had high validity and relevance and could serve as a starting point for a MIPS Value Pathway creation.

Last, strategies to incorporate practice setting and social risk into program design should be tested. 11, 36, 37 For example, the Hospital Readmissions Reductions Program compares hospitals within strata of their proportion of dualeligible patients, which has been associated with reductions in penalties to dual-eligible-serving hospitals. 38 Similarly, MIPS could investigate a similar strategy of assigning financial penalties within strata of practice size or setting. Providing incentive payments for improvements in quality, rather than solely achievement, may also benefit practices with lower baseline performance, such as smaller or HPSA practices.

There are several limitations to consider in interpreting our results. First, data in the Public Use File were deidentified so MIPS performance could not be linked to physician and practice characteristics through National Provider Information number, which would offer more detailed information on nephrologist characteristics. Similarly, information on patient clinical status is not linkable to these data. Last, we did not have data on submission type (eg, CMS web interface vs electronic health records, etc), which limited our ability to compare Quality measure scores with performance benchmarks to discern differences in quality of care.

In summary, MIPS APM participation, larger practice size, and practice setting were associated with higher MIPS performance among nephrologists. There is a discrepancy between high scores attained in MIPS and known opportunities to improve nephrology care. Our results point to areas in which the MIPS program needs substantial reform. These revisions could include a streamlined set of measures that reduces complexity and eases administrative burden and more meaningful scoring methodology that will drive improvements in care.

Supplementary File (PDF) 

Quality Payment Program Experience Report

The Medicare Access and CHIP Reauthorization Act: implications for nephrology

Four years into MACRA: what has changed? Semin Dial

Trends in blood pressure control among US adults with hypertension

Trends in angiotensinconverting enzyme inhibitor and angiotensin II receptor blocker use among those with impaired kidney function in the United States

Clinical characteristics of and risk factors for chronic kidney disease among adults and children: an analysis of the CURE-CKD registry

Trends in statin use among US adults with chronic kidney disease, 1999-2014

USRDS 2020 Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases

The COVID-19 pandemic converges with kidney policy transformation: implications for CKD population health

Association between patient social risk and physician performance scores in the first year of the Merit-Based Incentive Payment System

Association of clinician health system affiliation with outpatient performance ratings in the Medicare Meritbased Incentive Payment System

Time out-charting a path for improving performance measurement

Measuring quality in kidney care: an evaluation of existing quality metrics and approach to facilitating improvements in care delivery

Medicare program; specialty care models to improve quality of care and reduce expenditures

Improve quality, control spending, maintain access-can the Merit-Based Incentive Payment System deliver?

No permanent fix: MACRA, MIPS, and the politics of physician payment reform

Quality Payment Program. how MIPS eligibility is determined

Quality Payment Program special statuses

Quality Payment Program. Merit-based Incentive Payment System (MIPS) Scoring 101 Guide for Year 2

Plotting regression coefficients and other estimates

Active physicians in the largest specialties

First-year report cards from the Merit-Based Incentive Payment System (MIPS): what will be learned and what next?

National Quality Forum Rural Health Committee. Performance measurement for rural low-volume providers

Quality Through Collaboration: The Future of Rural Health

ACO affiliated hospitals increase implementation of care coordination strategies

The adoption and spread of hospital care coordination activities under value-based programs

Meaningful engagement of ACOs with communities

Variation of hospitalbased adoption of care coordination services by communitylevel social determinants of health

Using health information technology to manage a patient population in accountable care organizations

CKD awareness among US adults by future risk of kidney failure

MedPAC's urgent recommendation: eliminate MIPS, take a different direction

Congress Should Replace Medicare's Merit-Based Incentive Payment System

US physician practices spend more than $15.4 billion annually to report quality measures

Adjustment for social risk factors does not meaningfully affect performance on Medicare's MIPS clinician cost measures: study examines the impact of adjusting for individual and community social risk on clinician cost measure performance, part of Medicare's Merit-based Incentive Payment System

Does the Merit-Based Incentive Payment System disproportionately affect safety-net practices?

Association of the new peer group-stratified method with the reclassification of penalty status in the hospital readmission reduction program