MIPS and the Fantasy of Value-Based Simplicity

The promise of MACRA’s Quality Payment Program was to usher in a more rational, outcomes-focused Medicare reimbursement model. In practice, the Merit-based Incentive Payment System (MIPS) has evolved into a sprawling bureaucracy that consumes far more clinical time than it saves and undermines the very value-based principles it claims to champion. The Medical Group Management Association’s recent submission to the Office of Management and Budget confirms what many front-line administrators already know: MIPS, as it stands, is unworkable, especially for small to mid-sized practices that lack the informatics infrastructure of large health systems (MGMA 2023 Regulatory Burden Report).

MIPS’s scoring methodology, built on a complex tournament-style framework, pits practices against one another rather than establishing clear benchmarks for quality improvement. CMS continues to escalate performance thresholds without offering timely feedback on how clinicians are doing. The most recent MGMA data shows that 67 percent of medical groups find QPP reporting to be extremely or very burdensome, and that burden is compounded by opaque cost metrics that hold physicians accountable for outcomes they cannot influence, such as hospital charges or pharmacy spend outside their EHR ecosystem. A 2021 analysis published in Health Affairs also found that MIPS scoring was often statistically unreliable and offered no consistent correlation with actual quality of care delivered (Health Affairs, 2021).

The burden is even more acute in small and rural practices. These practices often cannot afford full-time quality reporting staff, leaving clinicians themselves responsible for navigating arcane measure definitions and attestation workflows. According to the American Medical Association, more than 40 percent of small physician practices consider exiting Medicare entirely if administrative burdens continue to escalate (AMA Advocacy Resource Center). When MIPS participation becomes a financial liability rather than a clinical opportunity, it accelerates consolidation and drives independent physicians into hospital-owned systems where burnout tends to increase and autonomy decreases.

Even the so-called solution of shifting to Advanced Alternative Payment Models (APMs) has proven hollow. CMS has recently added new Promoting Interoperability requirements and certified health IT usage mandates to APM participation that replicate the same bureaucratic bloat seen in MIPS. MGMA’s data shows that 94 percent of medical groups say participation in value-based care models has not lessened their regulatory workload. The argument that these models offer relief is no longer credible. Instead, they are an additional layer of administrative friction dressed in the language of transformation.

Meanwhile, CMS is proposing expansive updates to the HIPAA Security Rule that would demand deep IT overhauls from practices already struggling to recover from ransomware attacks and the Change Healthcare outage. The proposed changes require small groups to implement formalized cybersecurity risk modeling, designate dedicated security officers, and maintain complex documentation practices. These are essential for large systems with enterprise security budgets, but they are operationally impossible for a three-provider clinic with a shared office manager. The result is not just noncompliance—it is closure. The Association of American Physicians and Surgeons has already signaled that such updates could lead to mass exits from Medicare and Medicaid participation (AAPS, 2024 Comment Letter).

Prior authorization reform remains another glaring omission. According to the 2022 American Medical Association survey, 93 percent of physicians report that prior auth leads to delays in necessary care, and 34 percent say it has led to serious adverse events in their patients (AMA Prior Authorization Survey). Despite this, MGMA notes that most practices are still required to dedicate at least three staff members per request and juggle multiple payer platforms to fulfill them. The ongoing administrative weight is neither justifiable nor safe.

If CMS and Congress are serious about preserving independent practice, reducing clinician burnout, and promoting true value-based care, they must eliminate the tournament-style scoring model, realign reporting requirements with actual clinical workflows, and expand auto-credit for existing registry-based submissions. Simply put, if a quality initiative cannot be performed in the context of a normal patient visit using standard documentation practices, then it does not belong in a regulatory framework claiming to support modern care delivery.

Until that happens, programs like MIPS will remain a cautionary tale of how well-intentioned policy can metastasize into operational chaos, draining clinician time, eroding morale, and doing virtually nothing to improve patient outcomes.