Urologists in group practices or an alternative payment model (APM) score higher across categories within Medicare’s merit-based incentive payment system (MIPS) compared with those in individual practices, according to a study published recently in Urology Practice.1  

The study provides a glimpse into how the switch from a traditional fee-for-service to MIPS, which is a value-based care model, might affect the treatment landscape in urology, which serves large numbers of Medicare recipients. Under MIPS, physicians who exceed defined performance measures earn a payment bonus, whereas those who underperform receive a payment penalty.

“The COVID pandemic has altered the landscape more than anyone could have imagined,” said lead author Ridwan Alam, MD, MPH, of the James Buchanan Brady Urological Institute at Johns Hopkins University School of Medicine in Baltimore, Maryland. “However, if we can study and understand policy changes more readily, it puts us in a better position to protect not only the interests of our patients but also our urologists.”

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For the study, Dr Alam and colleagues analyzed data from 9055 urologists in the MIPS database for performance year 2018. At that time, physicians were encouraged to voluntarily participate in the new system. MIPS became mandatory for all Medicare-participating physicians in 2019.

Group Practices Perform Better

Urologists had an overall MIPS score of 86.9 on a scale of 0 to 100. Scores on 4 MIPS domains were 82.5 for quality, 88.9 for promoting interoperability, 74.4 for cost, and 37.3 (on a 0-to-40 scale) for improvement activities. Most urologists were in group practices or APMs (47.0% and 32.4%, respectively). Reflecting current trends in the specialty, only 20.6% of urologists were in an individual practice. Urologists in group practices and APMs had higher scores than individual urologists in all categories except cost. Urologists who graduated medical school more recently were more likely to be in group practices or APMs. Younger urologists tended to have higher MIPS scores.

Geographic Differences

In addition, the study showed practice patterns varied among the geographic sections of the United States as defined by the American Urological Association. Urologists in the southeastern and western sections of the United States were more likely to be in an individual practice, whereas group practice was more common in the northeastern section. APMs were dominant in the New York and New England sections.

Daniel Barocas, MD, MPH, a professor of urology at Vanderbilt University Medical Center in Nashville, Tennessee, said the goal of the MIPS program is to reduce incentives for “doing more” and increase incentives for providing better care. “The principle is sound. Health care expenditures currently account for about 18% of gross domestic product in the US, and the growth rate of health care expenditures is higher than the growth rate of the GDP, so that 18% is predicted to grow to almost 20% by 2028 if we don’t change things,” Dr Barocas said.

Large vs Small Practices

It remains unclear how smaller practices will fare under the MIPS program compared with larger practices. “Since practices must compete for the incentive payments, which come at the cost of penalties for other practices, the smaller practices with less infrastructure support may be at a disadvantage,” Dr Barocas said.

Mara R. Holton, MD, vice chair of the health policy committee for the Large Urology Group Practice Association (LUGPA), said the new system is unfortunately marginally relevant, with arbitrary criteria that create a bureaucratic and administrative burden without making any discernible improvements in patient care.

“Ultimately, this has very significant implications for access in rural areas, which often cannot support larger practices,” Dr Holton said. “This might then well contribute to consolidation into more central locations or incorporation into hospital systems, which can support the infrastructure necessary to attest to these metrics.”

Worse Access to Care Possible

There is growing appreciation that independent practices are a critical site for innovation, efficient delivery of care, lower-cost delivery of care, and maintenance of access to care, she said. The new system may be well-intended, but it paradoxically may have the ultimate effect of creating barriers to care.

“It remains to be seen if these can be constructed in such a way that takes into account input from clinical stakeholders so that pathways can be constructed that can be instituted across different clinical settings and provide meaningful value to patients,” Dr Holton said.


  1. Alam R, Clifton MM, Han M. Urologist scores in the era of the Merit-Based incentive Payment System (MIPS). Urol Prac. 2022; published online January 24, 2022. doi:10.1097/UPJ.0000000000000285
  2. https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1751-f 
  3. https://www.mgma.com/resources/government-programs/mgma-annual-regulatory-burden-report-2021