Changes in Patient Experiences and Assessment of Gaming Among Large Clinician Practices in Precursors of the Merit-Based Incentive Payment System

IMPORTANCE: Medicare’s Merit-Based Incentive Payment System (MIPS), a public reporting and pay-for-performance program, adjusts clinician payments based on publicly reported measures that are chosen primarily by clinicians or their practices. However, measure selection raises concerns that practices could earn bonuses or avoid penalties by selecting measures on which they already perform well, rather than by improving care—a form of gaming. This has prompted calls for mandatory reporting on a smaller set of measures including patient experiences. OBJECTIVE: To examine (1) practices’ selection of Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experience measures for quality scoring under the pay-for-performance program and (2) the association between mandated public reporting on CAHPS measures and performance on those measures within precursor programs of the MIPS. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included 2 analyses. The first analysis examined the association between the baseline CAHPS scores of large practices (≥100 clinicians) and practices’ selection of these measures for quality scoring under a pay-for-performance program up to 2 years later. The second analysis examined changes in patient experiences associated with a requirement that large practices publicly report CAHPS measures starting in 2014. A difference-in-differences analysis of 2012 to 2017 fee-for-service Medicare CAHPS data was conducted to compare changes in patient experiences between large practices (111-150 clinicians) that became subject to this reporting mandate and smaller unaffected practices (50-89 clinicians). Analyses were conducted between October 1, 2020, and July 30, 2021. MAIN OUTCOMES AND MEASURES: The primary outcomes of the 2 analyses were (1) the association of baseline CAHPS scores of large practices with those practices’ selection of those measures for quality scoring under a pay-for-performance program; and (2) changes in patient experiences associated with a requirement that large practices publicly report CAHPS measures starting in 2014. RESULTS: Among 301 large practices that publicly reported patient experience measures, the mean (IQR) age of patients at baseline was 71.6 (70.4-73.2 ) years, and 55.8% of patients were women (IQR, 54.3%-57.7%). Large practices in the top vs bottom quintile of patient experience scores at baseline were more likely to voluntarily include these scores in the pay-for-performance program 2 years later (96.3% vs 67.9%), a difference of 28.4 percentage points (95% CI, 9.4-47.5 percentage points; P = .004). After 2 to 3 years of the reporting mandate, patient experiences did not differentially improve in affected vs unaffected practices (difference-in-differences estimate: −0.03 practice-level standard deviations of the composite score; 95% CI, −0.64 to 0.58; P = .92). CONCLUSIONS AND RELEVANCE: In this cross-sectional study of US physician practices that participated in precursors of the MIPS, large practices were found to select measures on which they were already performing well for a pay-for-performance program, consistent with gaming. However, mandating public reporting was not associated with improved patient experiences. These findings support recommendations to end optional measures in the MIPS but also suggest that public reporting on mandated measures may not improve care.