Rural-Urban Differences in Performance of Clinicians Participating in MIPS

Research center:
Lead researcher:
Project funded:
September 2021
Project completed:
July 2023

The purpose of this research was to increase our understanding of the Merit-Based Incentive Payment System (MIPS) program performance of clinicians working in rural areas. Early review of MIPS performance data in 2018 suggests that 2% of clinicians were penalized with penalties as high as 5%. Even though only 2% of clinicians were penalized in the 2018 performance year, the performance scores vary substantially across clinicians and performance thresholds and penalties are scheduled to increase in the coming years. Clinicians participating in MIPS will have to perform well in MIPS to ensure financial viability going forward.

Since the MIPS program is dependent on technical infrastructure, there are concerns about the disparity in performance and reporting of quality measures for clinicians working in different settings, particularly in rural areas. For example, better resourced facilities may be able to take advantage of the scoring methodology under MIPS by reporting more than six quality measures. A recent Government Accountability Office (GAO) report suggested that clinicians practicing in rural areas have fewer resources and lack technical infrastructure to perform well in pay-for-performance programs such as MIPS. There is also some evidence that MIPS performance of rural practices and small practices is worse than the national average.

Several studies have highlighted MIPS performance disparity by the clinician's affiliation, practice size, location, safety-net status, and specialty types. A recent study found that clinicians practicing in safety net counties characterized by low education, low income, and high housing burden perform poorly in MIPS. Similarly, another study found that higher social-risk caseload was associated with lower performance and higher likelihood of negative payments among MIPS clinicians, even after accounting for complex patient bonuses designed to account for medical complexity and social risk factors of patients. Studies show that clinicians affiliated with health care systems and those who serve fewer patients with low socio-economic status and fewer medically complex patients can gain comparatively higher advantages from the MIPS program. Similarly, there is also some evidence that clinicians serving minority patients may perform poorly in the MIPS program.

Despite several studies on MIPS program performance, a detailed examination of the MIPS performance of rural clinicians is lacking. Our findings regarding rural clinician MIPS performance and spending are critical to identify appropriate policies to promote rural clinician performance under pay-for-performance programs. Moreover, our analysis regarding clinicians serving a large proportion of racial/ethnic minorities is fundamental to understanding how these programs affect clinicians serving minority populations, especially in rural areas.