MACRA – MIPS: Privilege and the Zero-Sum Game

Jim TateBy Jim Tate, EMR Advocate
MACRA/MIPS Subject Matter Expert
Twitter: @jimtate, eMail:

Over the holidays I have been thinking a lot about the MACRA & MIPS program. Maybe too much. Something about it doesn’t sit right with me. I have had a nagging sense that there was a flaw in the program. Something about it just seems wrong. First, I must offer a disclaimer. I am one of those who provides clarification and guidance in the fuzzy world of health information technology (HIT). My company, EMR Advocate, has worn many hats in the world of HIT consulting: Certification, Meaningful Use, Incentive Audits, Software Development, and now MACRA & MIPS. Our team makes a living by bringing simplicity to complexity. We’ve worked with providers, health care systems, technology vendors and associations to numerous to mention. We have saved these entities time and money and hopefully, somewhere at the end of the trail, have done our part to improve patient care.

The goal of MACRA – MIPS to replace pay-for-performance reimbursement for pay-for-value appears noble. It makes logical sense that better healthcare outcomes should be incentivized. Not too many arguments can be made in support of a payment system based solely on actions. So, I am down with the concept. “It’s all good” as they say on the backstreets, especially if providers are not being hammered with too much hoop jumping and unnecessary data collection. So, what is my problem? How about “zero-sum”?

The dictionary defines “zero-sum” as “a situation in which one person or group can win something only by causing another person or group to lose it”. The MIPS payment adjustments are a zero-sum game. All the negative payment adjustments will be equal to the positive payment adjustments. In the world of the zero-sum every win means a loss. In the world of MIPS payment adjustments money will be taken from some providers and given to other providers. It all depends on the provider’s MIPS score. Because there must be a winner, there must be a loser. The whole concept of a program that rewards some providers only at the expense of others has a nasty sting to it. Maybe if access to MIPS education and guidance was equitable things might not be so bad but that is not the case. CMS is aware the playing field is not level and states: “If clinicians do not receive sufficient information and assistance, they may struggle to succeed under the QPP or choose not to participate. This is of particular concern for small practices and clinicians in rural or medically underserved areas, who may lack the resources to fully engage in the QPP without customized technical assistance to meet practice-specific needs.”

A zero-sum reimbursement scheme does not pass the smell test as many providers and practices “may lack the resources to fully engage in the QPP without customized technical assistance to meet practice-specific needs”. That text is a smoking gun. The MIPS score will affect reimbursement and professional reputation, but the table is tilted to those who can afford “customized technical assistance to meet practice-specific needs”. I should know, I am one of those providing “customized technical assistance”. As I help providers boost their MIPS score I am aware for every winner I help create I am creating a loser. The coin has two sides. To bring competition into reimbursement models for healthcare is dangerous indeed. The concept of “privilege” comes into play.

This article was originally published on MIPS Consulting Blog and is republished here with permission.