Merit-based Incentive Payment System Research Articles

Medicare's Post-Acute Care Reimbursement Models as of 2023: Past, Present, and Future.

The Centers for Medicare & Medicaid Services is continually working to mitigate unnecessary expenditures, particularly in post-acute care (PAC). Medicare reimburses for orthopaedic surgeon services in varied models, including fee-for-service, bundled payments, and merit-based incentive payment systems. The goal of these models is to improve the quality of care, reduce health-care costs, and encourage providers to adopt innovative and efficient health-care practices. This article delves into the implications of each payment model for the field of orthopaedic surgery, highlighting their unique features, incentives, and potential impact in the PAC setting. By considering the historical, current, and future Medicare reimbursement models, we hope to provide an understanding of the optimal payment model based on the specific needs of patients and providers in the PAC setting.

Merit-Based Incentive Payment System: How Are Plastic Surgeons Performing?

Merit-based incentive payment system (MIPS) is a payment model implemented to promote high-value care through performance-based adjustments of Medicare reimbursements. Higher scores indicate superior performance in healthcare quality, efficiency, and interoperability, which can result in financial advantages. Given the paucity of literature, we aimed to characterize plastic surgery performance in MIPS. The Centers for Medicare and Medicaid Services (CMS) online data repository was queried for data on MIPS performance of plastic surgeons from 2019-2021. Descriptive analyses and multivariable logistic regression were conducted to identify predictors of receiving bonus payment for exceptional performance. Approximately 1400 surgeons were sampled in each year. The median number of Medicare beneficiaries and percent of dually eligible beneficiaries-eligible for Medicare and Medicaid-were higher in 2019 (p<0.001). Beneficiary median HCC risk score, which measures expected healthcare costs and needs based on health status, was lower in 2021 (p<0.001). The most common reporting schema was reporting as a group. Total MIPS score increased from 2019 to 2020 to 2021 (90.2 vs 96.4 vs 98.3, p<0.001), but quality score progressively decreased (98.8 vs 95.5 vs 89.90, p<0.001). Fewer physicians received positive adjustment and bonus payments in 2020 and 2021. Predictors of receiving bonus payments were reporting as an alternative payment model, practice size >24, and having 10-49% of dually eligible beneficiaries (p<0.05). Understanding performance of plastic surgeons in MIPS can guide future policy direction and ensure that high-quality care translates into improved patient outcomes across all fields and levels of social vulnerability.

Radiologists' 2021 Quality Reporting and Performance in Medicare's Merit-Based Incentive Payment System: Analysis by Practice Type.

Radiologists' 2021 Quality Reporting and Performance in Medicare's Merit-Based Incentive Payment System: Analysis by Practice Type.

Are Quality Scores in the Centers for Medicaid and Medicare Services Merit-based Incentive Payment System Associated With Outcomes After Outpatient Orthopaedic Surgery?

The Medicare Merit-based Incentive Payment System (MIPS) ties reimbursement incentives to clinician performance to improve healthcare quality. It is unclear whether the MIPS quality score can accurately distinguish between high-performing and low-performing clinicians. (1) What were the rates of unplanned hospital visits (emergency department visits, observation stays, or unplanned admissions) within 7, 30, and 90 days of outpatient orthopaedic surgery among Medicare beneficiaries? (2) Was there any association of MIPS quality scores with the risk of an unplanned hospital visit (emergency department visits, observation stays, or unplanned admissions)? Between January 2018 and December 2019, a total of 605,946 outpatient orthopaedic surgeries were performed in New York State according to the New York Statewide Planning and Research Cooperative System database. Of those, 56,772 patients were identified as Medicare beneficiaries and were therefore potentially eligible. A further 34% (19,037) were excluded because of missing surgeon identifier, age younger than 65 years, residency outside New York State, emergency department visit on the same day as outpatient surgery, observation stay on the same claim as outpatient surgery, and concomitant high-risk or eye procedures, leaving 37,735 patients for analysis. The database does not include a list of all state residents and thus does not allow for censoring of patients who move out of state. We chose this dataset because it includes nearly all hospitals and ambulatory surgery centers in a large geographic area (New York State) and hence is not limited by sampling bias. We included 37,735 outpatient orthopaedic surgical encounters among Medicare beneficiaries in New York State from 2018 to 2019. For the 37,735 outpatient orthopaedic surgical procedures included in our study, the mean ± standard deviation age of patients was 73 ± 7 years, 84% (31,550) were White, and 59% (22,071) were women. Our key independent variable was the MIPS quality score percentile (0 to 19th, 20th to 39th, 40th to 59th, or 60th to 100th) for orthopaedic surgeons. Clinicians in the MIPS program may receive a bonus or penalty based on the overall MIPS score, which ranges from 0 to 100 and is a weighted score based on four subscores: quality, promoting interoperability, improvement activities, and cost. The MIPS quality score, which attempts to reward clinicians providing superior quality of care, accounted for 50% and 45% of the overall MIPS score in 2018 and 2019, respectively. Our main outcome measures were 7-day, 30-day, and 90-day unplanned hospital visits after outpatient orthopaedic surgery. To determine the association between MIPS quality scores and unplanned hospital visits, we estimated multivariable hierarchical logistic regression models controlling for MIPS quality scores; patient-level (age, race and ethnicity, gender, and comorbidities), facility-level (such as bed size and teaching status), surgery and surgeon-level (such as surgical procedure and surgeon volume) covariates; and facility-level random effects. We then used these models to estimate the adjusted rates of unplanned hospital visits across MIPS quality score percentiles after adjusting for covariates in the multivariable models. In total, 2% (606 of 37,735), 2% (783 of 37,735), and 3% (1013 of 37,735) of encounters had an unplanned hospital visit within 7, 30, or 90 days of outpatient orthopaedic surgery, respectively. Most hospital visits within 7 days (95% [576 of 606]), 30 days (94% [733 of 783]), or 90 days (91% [924 of 1013]) were because of emergency department visits. We found very small differences in unplanned hospital visits by MIPS quality scores, with the 20th to 39th percentile of MIPS quality scores having 0.71% points (95% CI -1.19% to -0.22%; p = 0.004), 0.68% points (95% CI -1.26% to -0.11%; p = 0.02), and 0.75% points (95% CI -1.42% to -0.08%; p = 0.03) lower than the 0 to 19th percentile at 7, 30, and 90 days, respectively. There was no difference in adjusted rates of unplanned hospital visits between patients undergoing surgery with a surgeon in the 0 to 19th, 40th to 59th, or 60th to 100th percentiles at 7, 30, or 90 days. We found that the rates of unplanned hospital visits after outpatient orthopaedic surgery among Medicare beneficiaries were low and primarily driven by emergency department visits. We additionally found only a small association between MIPS quality scores for individual physicians and the risk of an unplanned hospital visit after outpatient orthopaedic surgery. These findings suggest that policies aimed at reducing postoperative emergency department visits may be the best target to reduce overall postoperative unplanned hospital visits and that the MIPS program should be eliminated or modified to more strongly link reimbursement to risk-adjusted patient outcomes, thereby better aligning incentives among patients, surgeons, and the Centers for Medicare ad Medicaid Services. Future work could seek to evaluate the association between MIPS scores and other surgical outcomes and evaluate whether annual changes in MIPS score weighting are independently associated with clinician performance in the MIPS and regarding clinical outcomes. Level III, therapeutic study.

Association between Anesthesia Group Size and Merit-Based Incentive Payment System Scores.

Association between Anesthesia Group Size and Merit-Based Incentive Payment System Scores.

Performance of Neurosurgeons Providing Safety-Net Care Under Medicare's Merit-Based Incentive Payment System.

Under the Merit-Based Incentive Payment System (MIPS), Medicare evaluates provider performance to determine payment adjustments. Studies examining the first year of MIPS (2017) showed that safety-net providers had lower MIPS scores, but the performance of safety-net physicians over time has not been studied. This study aimed to examine the performance of safety-net vs non-safety-net neurosurgeons in MIPS from 2017 to 2020. Safety-net neurosurgeons were defined as being in the top quartile according to proportion of dual-eligible beneficiaries and non-safety-net in the bottom quartile. Outcomes were total MIPS scores and dual-eligible proportion over time. In this descriptive study, we evaluated ordinary least squares regression models with SEs clustered at the physician level. Covariates of interest included safety-net status, year, and average Hierarchical Condition Category risk score of beneficiaries. There were 2796-3322 physicians included each year between 2017 and 2020. Mean total MIPS scores were not significantly different for safety-net than non-safety-net physicians in 2017 but were greater for safety-net in 2018 (90.7 vs 84.5, P < .01), 2019 (86.4 vs 81.5, P < .01), and 2020 (90.9 vs 86.7, P < .01). Safety-net status (coefficient -9.11; 95% CI [-13.15, -5.07]; P < .01) and participation in MIPS as an individual (-9.89; [-12.66, -7.13]; P < .01) were associated with lower scores while year, the interaction between safety-net status and year, and participation in MIPS as a physician group or alternative payment model were associated with higher scores. Average Hierarchical Condition Category risk score of beneficiaries (-.011; [-.015, -.006]; P < .01) was associated with decreasing dual-eligible case mix, whereas average age of beneficiaries (.002; [.002, .003]; P < .01) was associated with increasing dual-eligible case mix. Being a safety-net physician was associated with lower MIPS scores, but safety-net neurosurgeons demonstrated greater improvement in MIPS scores than non-safety-net neurosurgeons over time. Providers with higher-risk patients were more likely to decrease their dual-eligible case mix over time.

ACO Clinicians Have Higher Medicare Part B Medical Services Payments Than MIPS Clinicians Under the Quality Payment Program.

The Quality Payment Program (QPP) is a Medicare value-based payment program with 2 tracks: -Advanced Alternative Payment Models (A-APMs), including two-sided risk Accountable Care Organizations (ACOs), and Merit-based Incentive Payment System (MIPS). In 2020, A-APM eligible ACO clinicians received an additional 5% positive, and MIPS clinicians received up to 5% negative or 2% positive performance-based adjustments to their Medicare Part B medical services payments. It is unclear whether the different payment adjustments have differential impacts on total medical services payments for ACO and MIPS participants. We compare Medicare Part B medical services payments received by primary care clinicians participating in ACO and MIPS programs using Medicare Provider Utilization and Payment Public Use Files from 2014 to 2018 using difference-in-differences regressions. We have 254 395 observations from 50 879 unique clinicians (ACO = 37.86%; MIPS = 62.14%). Regression results suggest that ACO clinicians have significantly higher Medicare Part B medical services payments ($1003.88; 95% CI: [579.08, 1428.69]) when compared to MIPS clinicians. Our findings suggest that ACO clinicians had a greater increase in medical services payments when compared to MIPS clinicians following QPP participation. Increased payments for Medicare Part B medical services among ACO clinicians may be driven partly by higher payment adjustment rates for ACO clinicians for Part B medical services. However, increased Part B medical services payments could also reflect clinicians switching to increased outpatient services to prevent potentially costly inpatient services. Policymakers should examine both aspects when evaluating QPP effectiveness.

New CMS Merit-Based Incentive Payment System Value Pathway After Total Knee and Hip Arthroplasty: Preparing for Mandatory Reporting

This article discusses the implementation of a new Merit-Based Incentive Payment System Value Pathway (MVPs) applicable to elective total hip and total knee arthroplasty as created by Medicare and Medicaid Services (CMS) – the Improving Care for Lower Extremity Joint Repair MVP (MVP ID: G0058). We describe specific quality measures, surgeon-hospital collaborations, future developments with Quality Payment Program, and how lessons from early implementation will empower clinicians to participate in the refining of this MVP. The CMS has designed MVPs as a subset of measures relevant to a specialty or medical condition, in an effort to reduce the burden of reporting and improve assessment of care quality. Physicians and payors must be mindful of detrimental effects these measures in their current form may have on surgeons, institutions, and patients, including disincentivizing care for sicker or more vulnerable populations, and increased administrative costs. Early voluntary participation is crucial to gain valuable experience for the orthopedic community and in an effort to work alongside CMS to maximize care while minimizing cost for patients and burden for providers.

Value-based payment models and management of newly diagnosed prostate cancer.

To examine the effect of urologist participation in value-based payment models on the initial management of men with newly diagnosed prostate cancer. Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019, with 1 year of follow-up, were assigned to their primary urologist, each of whom was then aligned to a value-based payment model (the merit-based incentive payment system [MIPS], accountable care organization [ACO] without financial risk, and ACO with risk). Multivariable mixed-effects logistic regression was used to measure the association between payment model participation and treatment of prostate cancer. Additional models estimated the effects of payment model participation on use of treatment in men with very high risk (i.e., >75%) of non-cancer mortality within 10 years of diagnosis (i.e., a group of men for whom treatment is generally not recommended) and price-standardized prostate cancer spending in the 12 months after diagnosis. Treatment did not vary by payment model, both overall (MIPS-67% [95% CI 66%-68%], ACOs without risk-66% [95% CI 66%-68%], ACOs with risk-66% [95% CI 64%-68%]). Similarly, treatment did not vary among men with very high risk of non-cancer mortality by payment model (MIPS-52% [95% CI 50%-55%], ACOs without risk-52% [95% CI 50%-55%], ACOs with risk-51% [95% CI 45%-56%]). Adjusted spending was similar across payment models (MIPS-$16,501 [95% CI $16,222-$16,780], ACOs without risk-$16,140 [95% CI $15,852-$16,429], ACOs with risk-$16,117 [95% CI $15,585-$16,649]). How urologists participate in value-based payment models is not associated with treatment, potential overtreatment, and prostate cancer spending in men with newly diagnosed disease.

EXPLORING THE UTILIZATION OF MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) PROGRAMS IN WORKFORCE DEVELOPMENT

Abstract Measuring patient outcomes is a critical component of the HRSA funded Geriatric Workforce Enhancement Programs (GWEPs), which aim to improve the quality of care for older adult patients. In 2019, GWEPs were tasked with aligning patient outcomes with the CMS Merit-based Incentive Payment System (MIPS) program, which incentivizes quality care and patient outcomes. Collecting and using MIPS data effectively can be a challenging task, particularly when done across multiple levels of care. To address these challenges, the National Association of Geriatric Education Centers (NAGEC) created a workgroup to develop advocacy and solutions for patient outcomes. This symposium will discuss the utilization of MIPS as performance metrics across three GWEPs, the challenges in reporting these outcomes, and implications for future policy changes. This symposium’s primary objective is to explore how GWEPs can effectively measure patient outcomes, despite the challenges involved in collecting and utilizing MIPS data. By discussing these challenges and proposing potential solutions, this symposium aims to improve the effectiveness and sustainability of GWEPs, ultimately leading to better outcomes for older adult patients. Overall, measuring patient outcomes is critical for ensuring that older adult patients receive high-quality care that is tailored to their individual needs and preferences. Despite the challenges involved in collecting and utilizing MIPS data, our symposium provides an opportunity to explore potential solutions and advocate for policies that support improved patient outcomes in geriatric care.

REPORTING MERIT-BASED INCENTIVE PAYMENT SYSTEM LIKE DATA IN A UNIQUE AGE-FRIENDLY HEALTH CARE SETTING

Abstract The Richmond Health and Wellness Program (RHWP) offers screening, education, care coordination, and resources as an enhancement to primary care for older adults in five low-income apartment buildings and in a community center. Participants may receive primary care through multiple healthcare systems in the region that do not have a common electronic medical record (EMR). To track age-friendly workflows to the Health Resources Services Administration (HRSA) in the domains of advance care planning, falls prevention, and high-risk medication use, case note documentation in a REDCap database is used to generate Merit-based Incentive Payment System (MIPS)-like data. We report on advance care plans developed, fall risk screenings and risk reduction interventions implemented, high-risk medications screened, and referrals to primary care for high-risk medication deprescribing, including risk reduction with opioid use. When reporting MIPS data to HRSA, we include a disclaimer for RHWP data defining the numerator and denominator used for the MIPS-like measure calculation. For example, when reporting advance care plan completion, we include “RHWP is a care coordination site and care is not provided at the site. The population includes adults aged 55+ or people (of any age) with disabilities in low-income congregate living facilities and all adults participating in RHWP at the Virginia Commonwealth University Health Hub.” The numerator indicates the number of clients with advanced care plans created, and the denominator indicates the total number of clients seen during the reporting period. This presentation will provide strategies to meet reporting requirements when EMR records are not available.

DataDerm: Improving trends in performance measurement

Medicare’s legacy quality reporting programs were consolidated into the Merit-Based Incentive Payment System (MIPS) in 2015. The DataDerm registry of the American Academy of Dermatology was examined to understand the potential for and subsequent rate of improvement across 23 performance measures. The aggregate performance rate for each measure ranged from 20.4% for AAD 1 (Psoriasis: Assessment of Disease Activity), to 99.9% for measure ACMS 1 (Avoidance of Opioid Prescriptions for Reconstruction After Skin Resection). Three of 23 measures had an aggregate performance over 95%. The overall aggregate performance rate across all 23 measures was 81.2%, indicating an aggregate potential for improvement of 18.8% across the 23 measures.Nine performance measures reported across the first five years of DataDerm’s existence were tracked through time to understand trends in performance through time. The performance across the nine performance measures meeting the inclusion criteria consistently improved in the initial years (2016 through 2018) of DataDerm participation and showed some variation in 2019 and 2020.These data provide evidence that the very act of participation in a multi-institutional registry and tracking compliance with performance measures can lead to improvements in compliance with the performance measures and therefore improvements in quality of care.

Financial Implications of the Merit-Based Incentive Payment System for Surgical Health Care Professionals

This study describes financial implications of the merit-based incentive payment system for surgical health care professionals.

Utilization of high-cost prostate cancer therapies by oncologists in the merit-based incentive payment system (MIPS).

73 Background: TheMerit-Based Incentive Payment System (MIPS) is currently the only federally mandated value-based payment model for oncologists. MIPS uses cost and quality metrics to assign oncologists an overall MIPS score, where higher scores correspond to greater payments for practices. The extent to which MIPS delineates between oncologists administering high-cost anti-cancer therapeutics with unproven benefit is unknown. In this study, we investigated administration of low-value prostate cancer therapies by differently scored oncologists. Methods: We identified MIPS scores for oncologists using publicly available data for the year 2019. We cross referenced these scores with the 20% restricted sample of Medicare fee-for-service claims for 2019 using provider National Provider Identifications (NPIs). We then identified patients who were treated by these oncologists for prostate cancer using ICD-10 diagnosis codes for prostate cancer. Use of Sipuleucel-T (Provenge) and Radium Ra 223 dichloride (Xofigo), two low-value treatments with unproven benefit in prostate cancer, was identified using HCPCS codes in the claims file. The top 25 and bottom 25 percentile of oncologists based on their MIPS scores were identified using summary statistics. Odds ratios (OR) and corresponding confidence intervals (CI) were generated for Sipuleucel-T and Radium Ra 223 dichloride use by top 25 and bottom 25 percentile MIPS scores. Results: We identified 533,966 claims for prostate cancer treated by oncologists with a MIPS score in 2019. Of these claims, there were 100 instances of Sipuleucel-T use and 308 instances of Radium Ra 223 dichloride use (500 instances of Sipuleucel-T and 1540 instances of Radium Ra 223 dichloride if scaled to national use). Oncologists in the lowest 25% of MIPS scores less likely administered Sipuleucel-T (OR 0.25, 95% CI 0.12, 0.54) while those in the highest 25% did not show a significant trend (OR 1.36, 95% CI 0.90, 2.07). Oncologists in the lowest 25% of MIPS scores more likely administered Radium Ra 223 dichloride (OR 1.53, 95% CI 1.21, 1.95) while those in the highest 25% less likely administered the drug (OR 0.66, 95% CI 0.49, 0.88). Conclusions: Low MIPS scoring oncologists were less likely to utilize Sipuleucel-T and more likely to use Radium Ra 223 dichloride to treat prostate cancer. Our findings suggest that the MIPS program may be ineffective at measuring and incentivizing high value care among oncologists. Specialty-specific recalibration of cost and quality measures is needed to ensure that policy efforts to promote value-based care do not compromise healthcare quality and outcomes. [Table: see text]

Acquisition of Urology Practices by Private Equity Firms and Performance in the Merit-based Incentive Payment System.

Private equity is increasingly engaged in the acquisition of urology practices. The implications of strategies to enhance practice value deployed by these firms for patients are unclear. We conducted a retrospective study of urologist performance in the MIPS (Merit-based Incentive Payment System) program for 2017 to 2020 using national Medicare data from the Quality Payment Program file. The primary outcome was the overall MIPS score. Secondary outcomes included MIPS component scores (ie, quality, interoperability, improvement activities, cost) and the percentage of urologists receiving a bonus payment. Generalized estimating equations were used to estimate the relationship between private equity acquisition and outcomes using a difference-in-differences framework. Between 2017 and 2020, 181 urologists were in a urology practice acquired by private equity with MIPS data available the year before and after acquisition. Compared to urologists in practices not acquired by private equity, those in acquired practices had worse overall MIPS performance after acquisition (difference-in-differences estimate, -14 points, P = .04). The decrease in the overall score was driven by worse performance in the quality score (difference-in-differences estimate, -28 points, P < .001). Finally, acquisition resulted in a decrease in the percentage of urologists receiving bonus payments (difference-in-differences estimate, -43%, P < .001). Private equity acquisition of urology practices was associated with significantly lower MIPS performance. As private equity acquisition of urology practices becomes more prevalent, key stakeholders should ensure that the quality of patient care is maintained and that the involvement of for-profit entities in health care is being made transparent to patients.

Development of ovarian cancer biomarker electronic clinical quality measure: Lessons learned.

420 Background: ASCO received funding from the Gordon &amp; Betty Moore Foundation’s Diagnostic Excellence Initiative to develop and test a biomarker electronic Clinical Quality Measure (eCQM) in ovarian cancer. Methods: Working collaboratively with a Technical Expert Panel (TEP), ASCO staff explored the development of an eCQM, Appropriate Germline Testing for Ovarian Cancer Patients to assess the rates of testing for BRCA1/2 germline mutations in adult ovarian cancer patients. The measure underwent clinical workflow analysis; feasibility; face, empiric, and data element validity; and signal-to-noise reliability testing. Results: Feasibility testing indicated an inability to reliably differentiate between germline and somatic BRCA1/2 testing in an eCQM specification due to both a lack of specificity in existing codes, and inconsistent use of appropriate codes to reflect germline testing. Among the 32 individual clinicians across 12 testing sites, overall measure performance ranged from 6.25 to 100 percent, with a 52.3 percent mean performance score (95 percent CI [39.9, 64.7]), indicating a performance gap and variation in care in germline testing among the ovarian cancer patient population. Conclusions: This measure development effort illustrated a scenario where medical practice has advanced beyond current data availability and coding specificity in a way that impacts stakeholder ability to reliably assess the delivery of personalized cancer care and minimize the burden of that measurement. While we concluded the implementation of an eCQM to assess rates of germline testing in ovarian cancer patients was infeasible and premature, ASCO continues to advance the registry-based Clinical Quality Measure (CQM) version of the measure, as testing indicated the CQM is reliable, valid, and reflected continued variation in care. ASCO supports efforts to advance towards robust, meaningful digital quality measures using things like Fast Healthcare Interoperability Resources (FHIR) and Minimal Common Data Elements (mCODE) initiatives, which will enable more standardized data capture and increase the availability and utility of granular data needed for assessing quality cancer care. ASCO also seeks to expand the denominator of this measure to include additional cancer types where germline BRCA1/2 testing is appropriate. Denominator expansion will not only significantly broaden the impact of the measure, but also increase longevity of the measure’s potential use in cross-cutting reporting initiatives such as the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs).

S1762 Gastroenterologists Performance and Payments in the Merit-Based Incentive Payment System

S1762 Gastroenterologists Performance and Payments in the Merit-Based Incentive Payment System

Association Between Urologist Merit-Based Incentive Payment System Performance and Quality of Prostate Cancer Care.

We performed a study to evaluate the association between urologist performance in the Merit-Based Incentive Payment System (MIPS), and quality and spending for prostate cancer care. Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019 were assigned to their primary urologist. Associated MIPS scores were identified and categorized based on thresholds for payment adjustment as low (worst), moderate, and high (best). Multivariable mixed effects models were used to measure the association between MIPS performance and adherence to quality measures and price standardized spending for prostate cancer. Adherence to quality measures did not vary across MIPS performance groups for pretreatment counselling by both a urologist and radiation oncologist (low-76%, [95% CI 73%-80%], moderate-77% [95% CI 74%-79%], and high-75% [95% CI 74%-76%]) and avoiding treatment in men with a high risk of noncancer mortality within 10 years of diagnosis (low-40% [95% CI 35%-45%], moderate-39% [95% CI 36%-43%], high-38% [95% CI 36%-39%]). Men on active surveillance managed by high performers more likely received a confirmatory test (44% [95% CI 43%-46%]) compared to those managed by moderate (38% [95% CI 33%-42%]) performers, but not low performers (36% [95% CI 29%-44%]). There was no difference in adjusted spending across MIPS performance groups. Better performance in MIPS is associated with a higher rate of confirmatory testing in men initiating active surveillance for prostate cancer. However, performance was not associated with other dimensions of quality nor spending.

Hospital-physician Integration and Value-based Payment: Early Results From MIPS.

Hospital-physician integration is often justified as a driver of clinical quality improvement due to joint resources covering a broad spectrum of care. Value-based programs, such as the Medicare Merit-Based Incentive Payment System (MIPS), are intended to tie financial incentives to clinical quality, which may confer an advantage on such integrated practices. We assessed the relationship between hospital-physician integration and MIPS performance by comparing hospital-integrated practices and independent practices. This was a cross-sectional study using data from the Quality Payment Program for the performance year 2020. Physician practices with a valid MIPS composite score in performance year 2020. Hospital integration was based on whether at least 75% of a practice's physicians either billed most of their services using hospital outpatient department codes or billed through a hospital tax identifier. The primary outcome was the MIPS quality category score, and the secondary outcomes were the specific quality measures reported by practice groups. Of the 20 most frequently reported measures, 14 were common in both groups. No difference was observed in the quality category score between hospital-integrated practices and independent practices in either unadjusted comparisons or after adjusting for practice characteristics, including practice size, geography, specialty mix, and case mix. In the secondary outcome models for specific quality measures, hospital-integrated practices achieved higher scores on most overlap measures but not all. The findings on quality category score suggest that hospital integration does not confer much advantage in the context of MIPS quality performance.

Intraoperative hypotension in ambulatory surgery centers

Study objectivesTo measure the incidence of intraoperative hypotension (IOH) during surgery in ambulatory surgery centers (ASCs) and describe associated characteristics of patients and procedures. DesignRetrospective analysis. Setting20 ASCs. Patients16,750 patients having non-emergent, non-cardiac surgery; ASA physical status 2 through 4. InterventionsNone. MeasurementsWe assessed incidence of IOH using the definition from the Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS)—mean arterial pressure (MAP) < 65 mmHg for at least 15 cumulative minutes—and three secondary definitions: minutes of MAP <65 mmHg, area under MAP of 65 mmHg, and time-weighted average MAP <65 mmHg. Main results30.9% of ASC cases had a MAP <65 mmHg for at least 15 min. The incidence of IOH varied significantly, and was higher among younger adults (age 18–39; 36.2%), females (35.2%), and patients with ASA physical status 2 (32.8%). IOH increased with increasing surgery length, even when time-weighted, and was higher among low complexity (30.6%) than moderate complexity (28.8%) procedures, and highest among high complexity procedures (44.1%). ConclusionsThere was substantial occurrence of IOH in ASCs, similar to that described in academic hospital settings in previous literature. We hypothesize that this may reflect clinician preference not to intervene in perceived healthy patients or assumptions about ability to tolerate lower blood pressures on behalf of these patients. Future research will determine whether IOH in ACSs is associated with adverse outcomes to the same extent as described in more complex hospital-based surgeries.