More on Medicare & Medicaid

Health system clinicians perform better under Medicare value-based reimbursement

Those linked to health systems were 99% less likely to receive penalties and 29% more likely to receive performance bonuses.

Jeff Lagasse, Associate Editor

Clinicians who were affiliated with health systems had better performance scores and received fewer payment penalties and more payment bonuses under the Medicare merit-based incentive payment system than clinicians not affiliated with health systems, found a team led by Kenton Johnston, an associate professor of health management and policy at Saint Louis University's College for Public Health and Social Justice.

The investigation of the association between health system affiliations of clinicians and their performance scores and payments under Medicare value-based reimbursement was published online in the Journal of the American Medical Association.

Outpatient physicians' payments from Medicare will be increasingly tied to their performance under MIPS, with the authors estimating that payment penalties and bonuses will hit 9% of total Medicare reimbursement by 2022. Maximizing success in MIPS, they found, will require the management, administration and technological infrastructure to report performance measures to the Centers for Medicare and Medicaid Services.


The study used 2019 MIPS data to examine 636,552 clinicians' performance and found that those affiliated with health systems achieved mean performance scores of 79, on a scale of 0 to 100, versus 60 for unaffiliated clinicians. Physicians affiliated with health systems were 99% less likely to receive payment penalties and 29% more likely to receive exceptional performance bonus payments than physicians not affiliated with health systems.

Clinicians who affiliate with health systems appear to do substantially better under Medicare value-based payment, but clinicians could self-select the performance measures they were evaluated on, so it is unclear whether findings represent real differences in patient quality of care or other factors. That will be an area for future research.

Because the MIPS is effectively a zero-sum game, the financial consequences are that system-affiliated clinicians are recipients of greater Medicare payment resources at the expense of clinicians not affiliated with health systems.

This is likely to amplify the existing trend toward clinician consolidation within health systems as the former seek sophisticated analytics, informatics and administrative help to maximize performance and reimbursement under value-based payment programs.

MIPS, which is authorized under the Medicare Access and CHIP Reauthorization Act, is a mandatory pay-for-performance program for clinicians participating in Medicare in the outpatient setting. Clinician performance under MIPS looks at quality of care, meaningful use of electronic health records, improvement activities for patient care processes and cost.


As of April, providers may now earn credit in MIPS by contributing scientific research and evidence to fight COVID-19. CMS is encouraging clinicians to take MIPS credit for participating in clinical trials and reporting information to the COVID-19 clinical trials improvement activity.

To receive credit, clinicians must attest that they participate in a COVID-19 clinical trial using a drug or biological product to treat a patient with a coronavirus infection, and report their findings through a clinical data repository or clinical data registry for the duration of the study. 

The improvement activity provides flexibility in the type of clinical trial, which could include the traditional double-blind placebo-controlled trial to an adaptive or pragmatic design that flexes to workflow and clinical practice.

Twitter: @JELagasse
Email the writer: