Health Policy Journal Club, Health Policy, Advocacy, Health Care Administration, Social EM

Health Policy Journal Club: Risky Business

Adjusting payment for social risk 

Medicare's Merit-based Incentive Payment System (MIPS) is an episode-based scoring system within Medicare that evaluates the amount of reimbursement physicians receive for 19 pre-developed episodes of care; these range from elective arthroplasty to the inpatient management of intracranial bleeds. This scoring system is based on 4 weighted components: quality of care (45%); correctly using the EHR system with respect to information transfer and interoperability (25%); engaging in improvement activities such as shared decision making, patient safety, or care coordination (15%); and the overall cost and resource utilization (10%). Based on the score received, physicians or physician groups are given a reward (higher reimbursement) or a penalty (decreased reimbursement).

Currently, the cost component of the MIPS score includes, among other variables, adjustment for illness severity (community-acquired pneumonia vs. hospital-acquired pneumonia), patient medical complexity, and reason for Medicare eligibility. However, there is no adjustment made for social risk factors such as income, education, unemployment, housing, etc. Previous studies have shown that patients with the greatest burden of social disadvantage incur higher healthcare costs, and thereby, physicians caring for the most at-risk patients receive lower MIPS scores. The question then becomes: do clinicians caring for patients with greater social disadvantage receive appropriate reimbursement?

Sandhu et. al. evaluated the effect of community-level social factors on the average, episode-specific cost of care. After adjusting for social factors in multiple models for eight key episodes of care (5 procedures, two disease processes, and one screening procedure), the authors found that fewer than 4% of clinician groups experienced more than a 10% increase in the cost of care for these particular episodes of care.

The MIPS episode-based cost scoring system accounts for the clinically-related cost of care for certain conditions—not the overall cost of care (ie, the costs of ED readmissions, chronic disease management, or care coordination). If cost of care is studied in this restricted, particular manner, introducing adjustments for social risk factors will not affect the reimbursements healthcare systems receive. However, the large body of evidence presented above demonstrates that given the higher total cost of care, failing to account for social risk would take away money from healthcare systems that serve populations with higher rates of social risk. This in turn limits their ability to provide high-quality healthcare.


Medicare's Merit-based Incentive Payment System (MIPS) includes episode-based cost measures that evaluate Medicare expenditures for specific conditions and procedures. These measures compare clinicians' cost performance and, along with other MIPS category scores, determine Medicare Part B clinician payment adjustments. The measures do not include risk adjustment for social risk factors.

We found that adjusting for individual and community social risk did not have a meaningful impact on clinicians' cost measure performance. Across eight cost measures, 1.4% of clinician groups, on average, had an absolute change in their cost measure performance percentile of 10 percent or more (range, 0.4-3.4%). Prior analyses have generally found higher healthcare costs for patients with increased social risk.

MIPS episode-based cost measures are distinct from previous cost measures because they only include costs related to the specific condition being evaluated. This unique approach may explain why costs were similar for patients with high and low social risk before any risk adjustment.

MIPS episode-based cost measures do not appear to penalize clinicians who primarily care for patients with increased social risk.

PMID: 32897780

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.