Psychiatrists Feel the Financial Pinch of MIPS

Psychiatrists score lower than other physicians on Medicare’s Merit-Based Incentive Payment System (MIPS) and are more likely to incur payment penalties than other physicians who participate in the system, a study published in JAMA Health Forum has found. MIPS is a mandatory, outpatient value-based payment program under Medicare that ties reimbursement to performance on cost and quality measures.

“The increased administrative and financial burdens introduced by MIPS may further disincentivize psychiatrists from treating Medicare patients, resulting in an even greater number of psychiatrists who require patients to pay out of pocket for services,” wrote Kenton J. Johnston, Ph.D., M.P.H., an associate professor of health management and policy in the College for Public Health and Social Justice at Saint Louis University, and colleagues. “This factor has concerning implications for access to mental health care for Medicare beneficiaries.”

The researchers analyzed data from 9,356 psychiatrists and 196,306 other outpatient physicians who participated in the 2020 MIPS, which covered performance in 2018. The mean final MIPS performance score for psychiatrists was 84.0 compared with 89.7 for other physicians. Furthermore, 6.1% of psychiatrists received a penalty compared with 2.9% of other physicians, 92.6% of psychiatrists received a positive payment adjustment compared with 96.3% of other physicians, and 82.0% of psychiatrists received a bonus payment adjustment compared with 88.7% of other physicians.

MIPS adjusts Medicare Part B payments based on performance in four performance categories: quality, cost, promoting interoperability, and improvement activities. Most of the performance disparities were driven by lower scores in the quality and interoperability domains. For example, psychiatrists performed more poorly on measures such as participation in health information exchanges; documentation of patient medications; and preventive measures that are not related to psychiatry, such as cancer screening.

“The fact that just as many psychiatrists in our exploratory analysis reported on quality measures for cancer screening and flu shots as for depression care suggests that MIPS performance reflects multispecialty group performance as opposed to quality of psychiatric care,” the researchers wrote.

Yet psychiatrists are often not part of multispecialty group practices, instead choosing to go into solo practice. This can make it more difficult for them to benefit from MIPS, Johnston told Psychiatric News.

“It’s a system that disadvantages solo practitioners because they don’t have the infrastructure and management to report performance in a way that gets the biggest possible returns,” Johnston explained.

Psychiatrists in the study were much more likely than other physicians to see patients who had dual enrollment in Medicaid and Medicare: 56.6% of psychiatrists saw patients in this population compared with 26.7% of other physicians.

“This is a marker that they are treating a higher percentage of patients who are socially at risk,” Johnston said. He added that lower payments and greater penalties for psychiatrists may compound the barriers to access these patients already face.

“If Medicare and Medicaid are not paying high enough rates, psychiatrists have to offset that somehow,” Johnston said. “It puts psychiatrists between a rock and a hard place, because even though they may want to treat patients insured by Medicare or Medicaid, they have to limit the number of those patients to balance out their panel with patients who pay higher rates.”

Measures included in the mental/behavioral health specialty set, including measures related to depression, were rarely reported throughout the study. In an accompanying commentary, Marcela Horvitz-Lennon, M.D., M.P.H., senior physician scientist at the RAND Corporation and a professor at the Pardee RAND Graduate School in Boston, and colleagues wrote that this finding points to a need to develop and encourage the use of measures relevant to psychiatric care in MIPS. To that end, they offered two strategies for policymakers to consider.

“First, critically review and restructure the mental/behavioral health specialty set, which should include measures relevant to the patient populations most commonly served by Medicare psychiatrists,” they wrote.

“Second, use a different performance assessment method for psychiatrists, depending on the health and social complexity of their caseloads,” they added. They wrote that such changes may include fewer or no performance requirements for the interoperability, improvement activities, and cost domains for psychiatrists working in low-resource settings; addressing psychiatrists’ more socially complex caseloads by comparing performance between clinicians treating patients of similar social risk; and making psychiatrists’ participation voluntary.

However, Johnston feels that increased access to mental health care needs to come first.

“It would be great to have relevant performance measures, but we don’t have the luxury of grilling psychiatrists on quality of care when we haven’t met the first step of having enough psychiatrists in the first place,” Johnston said.

This study was supported by the National Institute of Mental Health. ■