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Improve Quality, Control Spending, Maintain Access—Can the Merit-Based Incentive Payment System Deliver?

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The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) seeks to accelerate the transition away from fee-for-service reimbursement and toward payment based on the quality and cost of the care providers deliver to patients. The law offers eligible physicians two payment pathways for ambulatory services: participation in advanced alternative payment models, including bundled payment or accountable care programs that include downside financial risk, or compensation through the new Merit-Based Incentive Payment System (MIPS), which links reimbursement to performance.

In a “Perspective” for the New England Journal of Medicine, The Commonwealth Fund’s Eric C. Schneider and Cornelia J. Hall explain MIPS, which went into effect in 2017, and highlight some of its potential intended and unintended consequences.

Program Flexibility: A Double-Edged Sword

To ease the transition, the Centers for Medicare and Medicaid Services (CMS) has granted physicians latitude to choose the quality measures that will contribute to their composite performance score. But the authors note that physicians may respond to the new system by choosing the combinations of measures and improvement activities that produce the most beneficial payment adjustments, but little actual quality improvement. The variety of options available to providers for reporting their performance data may make it difficult to compare providers.

Successful participation in MIPS may require physicians to enhance their staffing and information technology capabilities to ensure they support performance measurement, population health management, and feedback on quality and costs. While these steps may improve quality, the cost of these investments may compel smaller practices to close or consolidate, which could disrupt patients’ access to care.


Evaluating MIPS solely on the basis of measured quality, payment adjustments, and financial effects may be insufficient, the authors believe. To ensure the program’s success, CMS should monitor the system’s effects on access to care, clinician morale, patient experience, practice consolidation, migration to advanced alternative payment models, and progress toward innovative care models and team-based care.

Publication Details



Mary Mahon, Former Vice President, Public Information, The Commonwealth Fund

[email protected]


E. C. Schneider and C. J. Hall, “Improve Quality, Control Spending, Maintain Access—Can the Merit-Based Incentive Payment System Deliver?” New England Journal of Medicine, published online Jan. 18, 2017.