Unfair Playing Field? QPP Scoring May Hurt Physicians Not Hospital-Affiliated
By Joey Texas Medicine April 2019


In its young life, the Quality Payment Program (QPP) already has proven to be a challenge for physicians without extensive resources, as the Texas Medical Association has repeatedly warned the Centers for Medicare & Medicaid Services (CMS).

But as 2019 rolls on and physicians operate under new portions of the program’s Merit-Based Incentive Payment System (MIPS), many physicians may face an even bigger disadvantage — simply by virtue of not billing the vast majority of their services at a hospital.

Starting with the 2019 performance year, physicians whom CMS defines as “facility-based” — those who work primarily in hospital settings — can effectively cast aside their own scores in MIPS’ Quality and Cost categories. Instead, they can automatically use the hospital’s score under the Hospital Value-Based Purchasing Program (VBP), if it’s superior to their own scores.

Considering that physicians’ individual MIPS grades — and any bonuses or penalties they may earn as a result — will soon be dependent on all of the MIPS participants’ performance as a whole, real concerns exist that physicians who aren’t facility-based don’t have the same opportunity to succeed in the program.

Even a small-town physician who says his practice has no problem with QPP performance believes the impact of facility-based measurement could be detrimental.

Weimar family physician Jorge Duchicela, MD, owns his clinic and isn’t hospital-affiliated. He employs about 35 people full-time, including close to 20 medical assistants, and has been able to train them to perform all the documentation necessary to keep afloat on CMS reporting programs, dating back to meaningful use.

But knowing most other family physicians have much more limited help with quality reporting, Dr. Duchicela sees how facility-based scoring could make for a less equitable MIPS.

“When we have to do the quality measures, it’s a lot of non-clinical, non-face-to-face work and input that we have to do,” he said. “Let’s say that a physician like me — which [if] they are like that, they see a lot of Medicare patients — that somehow they can use the measures from the facility, the Columbus hospital [15 miles from me] in this case. That’s a huge advantage, I would think.”

CMS says the change is supposed to reduce reporting headaches for physicians. But the tradeoff could create an uneven playing field, says Angelica Ybarra, TMA director of clinical advocacy. TMA is monitoring the impact of what CMS calls “facility-based measurement” and whether the association will need to recommend changes to CMS for the 2020 version of MIPS.


To determine which physicians are facility-based for the 2019 performance year, CMS used physicians’ Medicare claims between Oct. 1, 2017, and Sept. 30, 2018. Physicians are considered facility-based — and able to use their hospital’s Quality and Cost scores for MIPS — if they:

• Billed at least 75 percent of their covered professional services in a hospital setting;
• Billed at least one service in an inpatient hospital setting; and
• Can be attributed to a facility with a Hospital VBP score.

Physicians can find out if they’re identified as facility-based by checking their participation status in the QPP website at qpp.cms.gov.

For qualified physicians, CMS will automatically apply their hospital’s VBP Quality and Cost scores to the MIPS Quality and Cost categories; physicians don’t have to submit their own data for those categories. But they can still do so at no real risk, because CMS will apply the higher of the two to the physician’s MIPS grade.

In a fact sheet, CMS says its goal in measuring performance at the facility level is to “reduce reporting burden for MIPS-eligible clinicians who are facility-based.”

The CMS fact sheet also says that as “value-based programs across different health care settings become more widespread, we will consider expanding this opportunity to other facility types and programs, as appropriate, in the future.”

Winners and losers

Ms. Ybarra says while TMA appreciates CMS’ effort to reduce the reporting burden for facility-based physicians, the policy doesn’t appear to be fair to Texas physicians in small and rural practices and may affect them adversely in the long run.      

She says many physicians continue to struggle with program participation, believe the quality and cost measures aren’t fair, and don’t believe the program will improve patient care quality. In addition, large group practices scored much higher in MIPS than small and rural practices during the 2017 performance year. (See “QPP 2017 Performance Results,” below.)


“Because there are ‘winners and losers’ in MIPS, higher performance scores contributed by facility-based measurement may skew the overall mean and median scores upward over time,” Ms. Ybarra said. “This is important because in future years CMS will set the MIPS performance target at either the mean or median final scores from a prior performance period. This increased performance target will make it more challenging for physicians to avoid a MIPS penalty.”

Dr. Duchicela also worries the facility-based distinction could make an impact beyond just quality scoring.

“It makes decisions more dependent on the hospital,” he said. “For example, if I’m trying to recruit a family physician here to my clinic, the hospitals already have an upper hand because they have more financial resources to pay [for] the first two years of a recruited family physician. Now, they have another advantage that is going to attract physicians. And also, it creates a dependency on [the hospital] that I don’t know if it is all that great for the [health care] system.”


Tex Med. 2019;115(4):44-46
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Last Updated On

August 02, 2019

Originally Published On

March 27, 2019

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