Can We Trust CMS’s MIPS as a Quality Measure?

We conducted a public search of the CMS Merit-based Incentive Payment System (MIPS) data for federally indicted cardiologists and found that their average score was 85 out of 100—with the highest reaching 97—suggesting a high level of care. Yet, this raises an important question: why does the data seem so favorable?

• Legal and Methodological Concerns: Some argue that the Department of Justice’s stance misses the mark. 
• MIPS itself is inherently flawed.

After reviewing the MIPS measures published by the American Academy of Orthopedics Surgeons several issues emerged.

• Primary Care Bias: The measures are often better suited to primary care than to surgical or interventional specialties.
• Self-Selected Metrics: Physicians can choose process-based measures that are easier to achieve rather than focusing on more meaningful, outcome-driven metrics.
• Limited Specialty-Specific Data: MIPS does not require mandatory reporting on outcomes that matter most to certain specialties, allowing for the selection of simpler, less impactful benchmarks.

Process Measures:

• Communication with managing clinicians post-fracture
• Osteoporosis screening
• BMI screening
• Medication documentation
• Depression screening
• Smoking cessation counseling

Outcome Measures:

• Unplanned reoperations within 30 days
• Postoperative readmission rates
• Surgical site infections
• Functional status after surgery

While many physicians follow the rules in good faith, some exploit loopholes to boost their scores:

• Upcoding & Data Manipulation: Reporting higher-severity diagnoses to justify better results and selectively reporting on low-risk patients.
• Cherry-Picking Patients: Only including healthier patients in reports to meet benchmarks.
• Misreporting Quality Measures: Utilizing automated templates in electronic health records (EHRs) to meet requirements falsely—for example, listing BMI screenings instead of more relevant surgical outcomes.
• Fake Participation in Improvement Activities: Claiming participation in care coordination or engagement activities without actual implementation.
• EHR Workarounds: Copy-pasting compliance data across multiple patients.
• Exploiting Exemptions: Claiming hardship exceptions to avoid proper reporting.
• Inflating Cost Savings: Avoiding necessary treatments to appear more cost-efficient.
• Third-Party Optimization: Hiring consultants to maximize MIPS scores by leveraging available loopholes.

When profiling doctors for value, cost is relatively straightforward to measure—but quality remains a complex challenge. Many doctor rating systems rely on MIPS as a quality indicator, which can lead to a distorted view of both care quality and healthcare value.

An alternative approach could involve evaluating a doctor’s work product directly. For example, tracking a patient’s longitudinal journey and measuring outcomes that truly matter after a procedure or surgery could provide more meaningful insights. These outcomes might include:

• Mortality Rate: Within one year of a procedure.
• Hospitalization Duration: Average number of days spent in the hospital following a procedure.
• Repeated Procedures: The frequency of repeated procedures on the same body part within three years.

Additionally, incorporating patient surveys that assess quality of life can offer a clearer picture of the true impact of care. Ultimately, doctors should be evaluated based on how their work affects their patients’ quality of life—whether positively or negatively.