Module 4
Quality and Value in Traditional Medicare
MIPS for clinicians and three payment adjustment programs for hospitals, plus an honest account of what more than a decade of fee-for-service pay-for-performance produced.
By the end of this module, you will be able to:
- Explain why MIPS penalties are fixed in statute while rewards cannot be forecast
- Compare the hospital value programs by mechanism and by who is penalized
- Summarize what the fee-for-service quality programs achieved and where they fell short
- MIPS and the Quality Payment Program MIPS adjusts every fee schedule payment a clinician receives, two years after the fact, on a budget-neutral curve. Here is how the machinery works. About 5 min
- The Hospital Value Programs Three programs adjust every hospital's Medicare payment for quality. One redistributes, one penalizes relative to peers, and one penalizes the bottom quartile by design. About 5 min
- What the Programs Achieved Medicare has run pay-for-performance in fee-for-service for over a decade. This lesson reports what it produced, including the parts that did not work. About 5 min
Module quiz
Answer all questions to see your score.
1. Why can a clinician not forecast their MIPS positive adjustment in advance?
The maximum penalty is fixed at 9 percent by statute, but the upside depends on the distribution of final scores. When few clinicians fall below the 75-point threshold, there is little money to redistribute.
2. What distinguishes the Hospital-Acquired Condition Reduction Program from an absolute quality standard?
Because the threshold is the 75th percentile of the distribution rather than a fixed standard, the program cannot signal that the field as a whole has succeeded.
3. What did MedPAC recommend about MIPS in 2018, and what happened?
MedPAC argued the program rests on a false unit of accountability and impedes movement toward high-value care. MIPS continues to operate, which illustrates the limits of advisory authority.