The Merit-based Incentive Payment System (MIPS) quality category assesses clinician performance by using standardized measures associated with CMS quality goals. Topped-out measures have low variability in performance with high scores for most clinicians. CMS limits these measures to 7 points after two years and potentially removes them after three. Almost half of the quality measures used for the Merit-based Incentive Payment System (MIPS) between 2017 and 2023 have been topped out, with many capped or removed, suggesting a premature loss of potentially useful measures despite the high cost of developing them.
The study utilized datasets from 2017 to 2023 that included Quality Payment Program experience data, quality measure lists, and benchmark files. The analysis includes 643,558 physicians throughout 37 specialties who reported 275 quality measures, with 137 (49%) classified as topped out. The study defined the cumulative reporting rate as the number of physicians who reported a measure at least once in any month before or in the year the measure was first marked as topped out or capped. This was used to assess the degree to which “topped out” reflects physician practice patterns.
The reporting rates were low. For topped-out measures, the median was 4.5% (interquartile range (IQR): 1.6%-22.5%), and the mean cumulative reporting rate was 14.7%. More than half of these measures had reporting rates of less than 5%, and only 8.1% exceeded 50%. The highest reporting rate was observed for influenza immunization (73%). Non-topped-out measures had lower engagement, with a median of 0.9% (IQR: 0.2%-6.7%) and a mean of 8.1%, showing that limited reporting is a system-wide issue. The variations were seen across different specialties. Among specific specialty topped-out measures, median reporting rates ranged from 40.4% in pathology to 0.62% in geriatric medicine.
Higher reporting specialties included anesthesiology (31.2%), nephrology (31.3%), oncology/hematology (32.4%), and diagnostic radiology (37.8%). Lower rates were seen in neurology (1.63%), psychiatry (1.5%), internal medicine (0.82%), and family medicine (1.1). In general, across 440 specialty-specific topped-out measures, non-topped-out measures had a median of 2.0% (IQR 0.36%–9.8%), and the median reporting rate was 7.1% (IQR 1.3%–28.2%).
Topped-out measures were irregularly distributed. Among 37 specialties, 26 (70.3%) had more than half of their quality measures classified as topped out. Several specialties had exceptionally high proportions, including diagnostic radiology (93.3%), general surgery (94.1%), radiation oncology (100%), anesthesiology (90.9%), plastic surgery (92.9%), and hospitalists (92.3%).
Many of these specialties had under six uncapped measures in 2023, making it hard for them to get high scores without using measures that are relevant to their specialty. Of the 305 specialty-specific measures that were subsequently capped, 94.4% had not been reported by the eligible physicians before the capping date. The median pre-cap reporting rate was 5.6% (IQR, 1.2% – 22.3%), but there was considerable variation between specialties, from 0.51% in infectious disease to 48.6% in diagnostic radiology.
The study indicates that topped-out status is often governed by a self-selected limited number of clinicians, presenting the risk of bias and overestimation of performance. Inconsistent and low reporting also hampers comparisons between doctors and specialties. The study recommends that CMS may be capping or dropping measures too soon, possibly impairing quality improvement. It identifies MIPS limitations and supports change, such as moving to MIPS Value Pathways (MVPs) and setting caps at the clinician or group level to improve comparability, equity, and long-term incentives for quality improvement.
Reference: Chung YK, Nicola LP, Rula EY. Reporting rates of topped-out merit-based incentive payment system (MIPS) quality measures, 2017-2023. Health Aff Sch. 2026;4(4):qxag061. doi:10.1093/hash/qxag061
