06 Sep MACRA at Ten: What a Decade of MIPS Performance Data Says About Physician Payment Adjustments
When Congress passed the Medicare Access and CHIP Reauthorization Act in 2015, it promised to fix something almost everyone in medicine hated: the Sustainable Growth Rate formula. SGR had a habit of threatening double-digit payment cuts to physicians almost every year, only for Congress to patch it at the last minute. MACRA killed that formula for good. In its place, it built a new system meant to tie Medicare Part B payments to performance rather than volume. That system, the Merit-based Incentive Payment System, started collecting real performance data in 2017. Physicians are now heading into roughly a decade of MIPS reporting history. That’s long enough to ask a fair question: did the program do what it was supposed to do? According to CMS, MIPS is designed to shift Medicare payments from volume-based to value-based reimbursement, with adjustments applied to Medicare Part B claims two years after the performance period based on composite scores across four weighted categories.
A Program Built to Reward Almost Everyone
MIPS was designed with a gentle on-ramp. In performance year 2017, the bar for avoiding a penalty was set at just 3 points out of a possible 100. CMS wanted clinicians to get comfortable with reporting before the program had real teeth. It worked, in the sense that almost nobody failed. The Government Accountability Office looked at performance years 2017 through 2019 and found that at least 93% of MIPS clinicians earned a positive payment adjustment. Fewer than 5% landed a negative one. That sounds like a success story until you look at the size of those positive adjustments. The highest positive adjustment in those early years topped out at 1.88%. The median positive adjustment ranged between roughly 1.27% and 1.66%. Those numbers matter because MIPS is budget neutral by design. Bonuses paid to high scorers come out of the penalties collected from low scorers. When almost nobody scores low, there isn’t much money left to fund meaningful bonuses. A program engineered to reward high performers ended up rewarding almost everyone a little, which is functionally the same as rewarding no one very much.
The Threshold Climbs, and the Math Doesn’t Change Much
CMS raised the performance threshold steadily over the following years, from 3 points in 2017 up to 75 points, where it has sat since the 2023 performance year. CMS has now committed to holding that threshold at 75 points through the 2028 performance period, giving practices a rare stretch of predictability after years of a moving target. But a higher bar didn’t fix the underlying budget neutrality problem. For performance year 2023, paid out in 2025, CMS reported a mean final score of 82.91 and a median final score of 85.49 — well above the 75-point threshold, meaning most clinicians are still clearing the bar comfortably. The mean payment adjustment that year was 0.56%. The median was 0.90%. The maximum positive adjustment anyone received was 2.15%. Compare that to the penalty side. The statutory maximum negative adjustment has been 9% since 2022. In practice, most clinicians never come close to touching it. The gap between what MIPS could theoretically do to a practice’s revenue and what it actually does in a typical year is enormous.
What MedPAC Thinks a Decade of This Looks Like
The Medicare Payment Advisory Commission has been skeptical of MIPS almost since it launched. In its March 2018 report to Congress, MedPAC recommended eliminating the program entirely. The Commission’s reasoning still holds up years later. MIPS adjustments would start small and offer little incentive, then grow arbitrary and large enough to create real financial uncertainty for clinicians, without a clear link to better patient outcomes. MedPAC also raised a structural concern that’s aged well. Because clinicians can choose their own quality measures from a large menu, two practices treating similar patients can report on completely different things. That flexibility was meant to make MIPS fair across specialties. In practice, it makes it hard to say the program meaningfully distinguishes high-value care from low-value care. MedPAC’s preferred alternative, a voluntary value program built around larger group-level accountability, hasn’t replaced MIPS. But the Commission has continued to argue that MIPS still doesn’t meaningfully differentiate quality of care and that Advanced APMs remain the more promising path for real payment reform.
The Categories Have Shifted Under Practices’ Feet
Ten years in, the four MIPS performance categories — Quality, Cost, Improvement Activities, and Promoting Interoperability — look nothing like they did in year one. Cost started at 0% weight in 2017 specifically so clinicians wouldn’t be penalized before CMS had reliable claims-based cost measures built out. That weight climbed gradually until it reached parity with Quality at 30% each, where both categories have remained for the 2026 performance year alongside Promoting Interoperability at 25% and Improvement Activities at 15%. That evolution has mattered more for some specialties than others. Groups that qualify for special statuses — hospital-based, non-patient-facing, or small practice — often see Promoting Interoperability reweighted to zero, which pushes Quality up to 85% or even higher of the total score. A specialty with a narrow measure set and a compressed benchmark distribution can end up far more exposed to a single bad measure than a specialty spreading that same weight across a dozen options.
Not Everyone Rode the Same Curve
A five-year longitudinal study of MIPS performance found that the rewards weren’t distributed evenly across the physician population. Safety-net providers — practices serving a disproportionate share of low-income or medically complex patients — consistently scored lower and were more likely to land negative adjustments than practices with fewer socially at-risk patients. Small practice size showed a similar pattern. That finding lines up with concerns raised as far back as MACRA’s original rulemaking process, when commenters warned that small and rural practices would struggle to absorb the upfront reporting and technology costs MIPS requires. A decade later, those practices are still more likely to end up on the losing side of a budget-neutral redistribution, even though the final composite score itself was never risk-adjusted for the patient population a practice actually serves.
For a lot of these groups, the technical complexity of the program is as much of a burden as the financial risk. Measure selection, benchmark modeling, and category reweighting all interact in ways that aren’t obvious from CMS’s published guidance alone. Practices that treat these as connected decisions, instead of separate year-end tasks, tend to come out ahead of practices that don’t. That’s part of why so many groups now bring in outside expertise for Merit-based Incentive Payment System (MIPS) reporting rather than rebuilding their strategy from scratch every performance year, especially as the rules underneath the program keep shifting even while the headline threshold stays flat.
Where the Next Decade Is Headed
CMS has been fairly candid that traditional MIPS, as most practices know it today, may not last another ten years. MIPS Value Pathways, introduced as an optional alternative to the traditional reporting structure, bundle Quality, Cost, and Improvement Activities measures around a specific specialty or condition instead of letting clinicians assemble their own mix from an open menu. CMS has signaled that traditional MIPS could sunset as early as the 2029 performance period, which would make MVPs the only reporting pathway left for clinicians who aren’t in an Advanced APM. That shift would address one of MedPAC’s longest-standing criticisms — the comparability problem created by letting every clinician pick their own measures. MVPs are still new enough that most groups are reporting through traditional MIPS or a Qualified Clinical Data Registry rather than adopting an MVP voluntarily. But the direction of travel is clear enough that practices building multi-year reporting strategies should probably be modeling for an eventual transition.
What Ten Years of Data Actually Tells Physicians
Strip away the politics, and a decade of MIPS performance data tells a fairly consistent story. The program has been extremely good at avoiding penalties for the vast majority of clinicians and extremely modest in what it actually pays out to anyone. It has been less successful at doing the thing it was designed to do: meaningfully separate high-value care from low-value care and reward the difference in a way large enough to change behavior. For an individual practice, none of that history changes the immediate math. A score below 75 points still produces a real negative adjustment two years later, and that adjustment lands on Medicare Part B claims regardless of how small the average positive adjustment has been for everyone else. The lesson from a decade of data isn’t that MIPS doesn’t matter. It’s that the program rewards preparation far more than it rewards clinical excellence alone, and that the practices consistently clearing the threshold are the ones treating measure selection, category weighting, and status determination as one coordinated strategy rather than three separate scrambles at year end. Whether MIPS looks anything like its current form by year twenty is an open question that CMS itself seems to be actively rethinking. Until that transition happens, the program’s decade-long track record is the best guide practices have for what actually moves the needle on their Medicare payments — and what doesn’t.
For a broader overview of how CMS value-based care programs including MIPS and Advanced APMs are reshaping Medicare reimbursement strategy for physician practices, see this MedicalResearch.com overview of value-based care and Medicare reimbursement — what physicians need to know.
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Last Updated on September 6, 2026 by Marie Benz MD FAAD