PAI’s Research Digest is a periodic roundup of research on topics that are of interest to physicians and organizations that represent them. We hope you’ll find this information valuable to efforts to champion the important role that physicians play in our healthcare system.
I also urge you to review PAI’s studies on several related topics as part of its ongoing commitment to providing high level research to support physician advocacy initiatives at the federal, state and local levels.
Kelly Kenney
Chief Executive Officer, Physicians Advocacy Institute
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California Medical Association - Connecticut State Medical Society - Medical Association of Georgia - Medical Society of the State of New York - Nebraska Medical Association - North Carolina Medical Society - South Carolina Medical Association - Tennessee Medical Association - Texas Medical Association
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Medicare: Provider Performance and Experiences under the Merit-based Incentive Payment System
United States Government Accountability Office | October 2021
The Government Accountability Office (GAO) released a report examining the distribution of the Merit-based Incentive Payment System (MIPS) performance scores and related payment adjustments as well as stakeholders’ perspectives on the strengths and challenges of the MIPS program. GAO analyzed MIPS data for performance years 2017 to 2019 and interviewed officials from the Centers for Medicare & Medicaid Services (CMS) and 11 selected professional organizations that represent MIPS-eligible physicians of various specialties. Key highlights from the report are outlined below:
- Final scores for MIPS physicians were generally high and at least 93% of physicians earned a small positive adjustment, with the largest payment adjustment in any year being 1.88%.
- Median final scores were well above the performance threshold across each of the 3 years.
- About 72 to 84% of physicians earned an exceptional performance bonus, depending on the year.
- Two of the eleven stakeholders stated that bonus points, such as those that may be added to the final scores for small practices, helped increase scores for certain physicians who might otherwise be disadvantaged.
- Eight stakeholders questioned whether the program helps to meaningfully improve quality of care or patient health outcomes.
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Competition in Health Insurance: A Comprehensive Study of
U.S. Markets
American Medical Association, Division of Economic and Health Policy Research | September 2021
The American Medical Association released their annual U.S. health insurance market concentration study. The newest analysis found that nearly three-quarters (73%) of all metropolitan statistical areas are highly concentrated health insurance markets, based on the Department of Justice and the Federal Trade Commission’s horizontal merger guidelines. The study also found that:
- In 91% of the markets, a single health insurer had a market share of 30% or more and in 46% of the markets, a single health insurer’s market share was at least 50%.
- 57% of the markets saw their contraction index rise, and the increase was at least 500 points in 21% of the markets.
- Highly concentrated markets increased from 71% to 73% of all markets between 2014 and 2020.
- More than half (54%) of markets that were highly concentrated in 2014 became more so by 2020.
- 26% of health insurance markets that were not considered highly concentrated in 2014 shifted to highly concentrated by 2020.
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2021 Survey of America’s Physicians COVID-19 Impact Edition:
A Year Later
Physicians Foundation | June 2021
The Physicians Foundation released 2021 survey results examining how the COVID-19 pandemic has affected the nation’s physicians. The report is based on responses from 2,504 physicians collected between May 26 and June 9, 2021. The survey found that 61% of physicians reported experiencing burnout in 2021, up from 40% in 2018, prior to the pandemic. Some additional key survey findings include:
- Slightly more employed physicians (64%) reported burnout compared to independent physicians (57%).
- Primary care physicians were slightly more likely (66%) than medical and surgical specialists (59%) to report burnout.
- A significant majority of female physicians (69%) reported often feeling burned out, compared to 57% of their male counterparts.
- More than half of all physicians surveyed (57%) reported inappropriate feelings of anger, tearfulness or anxiety because of the COVID-19 pandemic, while 14% of physicians said they have received medical attention for a mental health problem and 20% of respondents reported knowing a colleague who has either considered, attempted or died by suicide during the pandemic.
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State Action to Oversee Consolidation of Health Care Providers
Milbank Memorial Fund | August 2021
The Milbank Memorial Fund released an issue brief highlighting that although most health care markets are highly concentrated, federal agencies as well as state anti-trust enforcement agencies must remain vigilant to protect the remaining competitive health care markets and minimize further market consolidation. According to the authors of this issue brief, key components of a comprehensive merger review include:
- Notice of Impending Transactions to better monitor consolidation and to prevent and address any potential harms to competition.
- Pre-transaction Review that includes sufficient time and authority to properly assess whether the proposed transaction serves the public, preserves access to affordable health care, and does not significantly harm competition. Merger review criteria should be uniform; provide more discretion in statute to regulators; and involve sub-regulatory review protocols.
- Pre-transaction Approval Authority that allows for both the approval or denial of a transaction without having to go to court.
- Conditional Approvals/Consent Decrees and Post-transaction Oversight are all important elements of a sound process of review and evaluation of potentially anticompetitive mergers. In all cases, it is imperative that there are specific conditions selected to minimize harm and achieve the desired benefit of the market consolidation. The merged entity must also be closely monitored to ensure compliance and that all the conditions delivered their intended effects.
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Higher and Faster Growing Spending Per Medicare Advantage Enrollee Adds to Medicare’s Solvency and Affordability Challenges
Kaiser Family Foundation | August 2021
The Kaiser Family Foundation released an analysis examining Medicare spending per person for beneficiaries in Medicare Advantage (MA), relative to traditional Medicare. The number of people enrolled in Medicare, along with its spending, has increased since its inception. In the last decade, there has also been a significant increase in MA enrollment – with enrollment doubling in the last decade. Publicly available data from CMS was used in this study. Findings include:
- Medicare spending for MA enrollees was $321 higher per person in 2019 than if enrollees had been covered by traditional Medicare. This difference in spending contributed to an estimated $7 billion in additional spending in the Medicare program in 2019.
- The growth in MA enrollment only explains half of the projected increase in total MA spending between 2021 and 2029, while half is attributable to growth in Medicare payments per MA enrollee (adjusting for inflation).
- Using Medicare Payment Advisory Commission protections and recommendations for MA plan payments could save $82 billion between 2021 and 2029. If Medicare payments for MA plans grew at the same rate as is projected for traditional Medicare spending (per person), total Medicare spending would be $183 billion lower between 2021 and 2029.
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Association Between the Physician Quality Score in the Merit-Based Incentive Payment System and Hospital Performance in Hospital Compare in the First Year of the Program
JAMA Network Open | August 2021
JAMA released a study investigating the scientific validity of the MIPS quality score as a measure of hospital-level patient outcomes. Specifically, this study looked at whether better physician performance on the MIPS quality scores is associated with improved hospital outcomes. Linear regression was used to examine this association (measuring postoperative complications, failure to rescue, individual postoperative complications, and readmission). This study had a cohort of 38,830 clinicians and included a number of surgical specialties. A major takeaway from this analysis is that high physician MIPS scores may not translate into better hospital outcomes or be great indictors of clinical quality. Key results included:
- Overall, better performance on the physician MIPS quality score was associated with better hospital surgical outcomes for some physician specialties during the first year of the MIPS program. However, the MIPS quality score was not associated with the hospital composite rate of postoperative complications.
- MIPS quality scores for a percentage of vascular surgeons were associated with higher hospital rate of failure to rescue. MIPS quality scores for some cardiac surgeons were associated with higher hospital coronary artery bypass graft (CABG) mortality rate.
- MIPS quality scores for some cardiac surgeons were associated with higher hospital CABG readmission rates.
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Some Medicare Advantage Companies Leveraged Chart Reviews and Health Risk Assessments to Disproportionately Drive Payments
U.S. Department of Health and Human Services Office of Inspector General | September 2021
The Office of Inspector General (OIG) released a report indicating that risk-adjusted payments may create financial incentives for MA companies to make beneficiaries appear as sick as possible. CMS risk-adjusts payments by using beneficiaries’ diagnoses to pay capitated payments to MA companies for beneficiaries expected to have higher than average medical costs. OIG found that:
- 20 of the 162 MA companies drove a disproportionate share of the $9.2 billion in payments from diagnoses that were reported only on chart reviews and health risk assessments (HRAs) and on no other service records.
- The higher share of payments for these MA companies could not be explained by the size of their beneficiary enrollment.
- Each of these 20 companies generated a share of payments from these chart reviews and HRAs that was more than 25% higher than its share of enrolled MA beneficiaries.
OIG provided CMS with the following recommendations:
- Provide oversight to the 20 companies that had a disproportionate share of risk-adjusted payments;
- Take additional actions to determine appropriateness of payments and care; and
- Perform periodic monitoring to identify MA companies that had a disproportionate share of risk-adjusted payments from chart reviews and HRAs.
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Health Equity from an Actuarial Perspective
American Academy of Actuaries | September 2021
The American Academy of Actuaries published a discussion brief exploring if and how methodologies or approaches actuaries use to develop financial models and identify physicians for network participation may contribute to health disparities. Health plans contract with physicians and other health care providers to develop networks to serve their members. These contracts establish a health plan’s reimbursement for services and other terms of network participation. However, these methodologies do not typically account for physicians’ patient mix, putting physicians who treat high risk patients at a disadvantage. This thoughtful report on how these methodologies for evaluating reimbursement levels and network participation may impact health equity or health care disparities focuses on the following areas/questions:
- How do overall health plan spending goals or other outcome goals and considerations affect network development and physician contracting, and do they have effects on access to care and health disparities?
- How do alternative payment models (APMs) and cost targets for risk-bearing contracts affect physician incentives and disparities in health care access and outcomes?
- Are quality provisions and outcome measures in APM contracts aligned with achieving equitable health outcomes?
- How do the risk adjustment methods used in physician contracting and network development affect access to care outcomes?
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