Examining the Cost and Quality Relationship in Medicare

Purpose. The purpose of this study is to evaluate the cost and quality of care dynamic among physicians billing under Medicare Fee for Service in 2018 to examine the relationship between quality and total cost of care at the physician level. Examining this relationship will advance scientific knowledge regarding the impact of increasing high value service use on healthcare costs and will provide insight in terms of expected cost outcomes of quality programs for healthcare policymakers (Salmond and Echevarria 2017; Williams, Brown, and Healy 2018). Methods. The study used publicly available data sets provided by the Center for Medicare and Medicaid Services (CMS) for the entire United States. The study used the 2018 Medicare Fee-For-Service Provider Utilization and Payment Data Physician and Other Suppliers Public Use File. This proposed analysis examined the cost and quality of care dynamics among providers reporting under the Merit-Based Incentive Payment System (MIPS) program. Quality was evaluated in two manners: 1) measured by the MIPS program and the quality score calculated for a provider and 2) assessed based on the providers likelihood to utilize high value services. Results. In both raw and adjusted results, high cost category physicians were more likely to be in the low category Level of Care Index (aOR 3.69; 95% CI 3.24-4.19). Results in the raw and adjusted models utilizing the MIPS score as the quality measure, we found that high costs physicians are less likely to be high category quality (aOR 0.50, 95% CI 0.46-0.54) and more likely to be low category quality (aOR 2.18, 95% CI 0.46-0.54) as compared to medium category quality score physicians. Conclusions. The results support the need for more research to determine whether quality scores as self-reported through MIPS are valid for assessment of a physician’s quality level. Additional research is needed to examine the types of services (low or high quality) provided to evaluate the validity of the MIPS as a measure of quality. As the MIPS score is the current standard for quality measurement, a broader understanding of the limitations of its use is necessary for both interpreting current program impacts and improvement, as well as identifying any future necessary policy changes for program success