A recent analysis suggesting ophthalmologists that participated in the Merit-based Incentive Payment System (MIPS) in 2017 earned higher scores than other physicians—including optometrists—is drawing fire among the profession and its advocates.

Published in the journal Ophthalmology, the paper states that ophthalmologists had significantly higher MIPS scores in all categories compared with optometrists and other physicians.1 Specifically, the paper reports the mean final MIPS scores for ophthalmologists in 2017 were 10 to 20 points higher than optometry and other physician specialties in both group and individual reporting. The authors also noted that ophthalmologists are more likely to perform at a higher level in MIPS.

Citing the AOA's 2018 American Eye-Q Survey, optometrist Jeffrey Michaels suggests that ophthalmology knows optometry is the preferred source for eye care in America and that optometrists are trusted more than any other source for ocular health exams.

“Ophthalmology is grasping at any conclusion they can to prove their worth, and the article contradicts the viewpoint of their own most experienced ophthalmologists,” says Dr. Michaels, who is a member of the AOA Quality Improvement and Data Committee. “As optometrists continue to expand scope of practice across the country, the opposition begins to show their desperation to reach out any way they can.”

Advocates say the data, which came out in 2017 when the Centers for Medicare & Medicaid Services rolled out the program, should be taken with a grain of salt.

That year, CMS granted widespread flexibilities to help ease providers into the MIPS program, making available a “pick your pace” participation that allowed three reporting options for clinicians, including test, partial or full-year reporting.2 The first option allowed providers to report “some data” to avoid a negative adjustment and gain familiarity with the program, while the latter options stepped up data requirements and incentives or penalties.2

Additionally, the overall performance threshold for MIPS was established at a relatively low level of three points out of a possible 100, and ODs earned far above that with an average of 55 points.2 The AOA affirms nearly every OD who participated in MIPS during 2017 earned a passing score.2

MIPS combines elements of the former Physician Quality Reporting System, value-based modifier and the EHR meaningful use program into one quality payment program that issues a composite performance score annually for eligible providers.Although performance for MIPS began broadly in 2017, CMS gradually rolled out the program with that year acting as a transitional period, but also narrowed criteria for eligible providers based on strong feedback.2

The group reporting database included 6,776 ophthalmologists, 12,206 optometrists and 231,285 other physicians. The individual clinician database included 8,595 ophthalmologists, 15,193 optometrists and 293,210 other physicians.

MIPS is still relatively new and not well understood by most doctors of optometry, and as is true for all health care providers, assessing quality of care based on whether a box in an EHR was checked or not doesn’t insure the accuracy of the care reported, nor does it insure the quality of care provided, says optometrist Chris Wroten, partner at the Bond-Wroten Eye Clinics in Louisiana and adjunct professor at Southern College of Optometry.

“It’s simply a metric, and caution should be exercised in drawing too many conclusions at this point,” Dr. Wroten says.

Ophthalmology has a built-in advantage in its exclusive IRIS registry, which streamlines reporting for MIPS and enhances scoring, Dr. Wroten adds.  Additionally, several eye care quality measures developed through the IRIS registry and then approved by CMS exclude optometry’s participation and compel ODs to use other topped out quality measures with maximum scores that are capped at 70% or less than the maximum available for other measures.  

“Further, CMS has acknowledged from the start of MIPS that it favors providers in large practices which have more resources to assist with compliance and reporting requirements.  A much higher percentage of MIPS-eligible ophthalmologists practice within hospital systems, multi-specialty groups, and large eye care clinics compared to doctors of optometry, further explaining any potential discrepancy in MIPS scores,” Dr. Wroten says.

In representing doctors of optometry, a profession rooted in medical science, the American Optometric Association (AOA) upholds meaningful research efforts to further examine the role that MIPS may play in supporting high quality patient eye health and vision care. The recent study fails to meet those needs and the AOA has serious concerns with the overall value of the study,” says AOA President William T. Reynolds, OD. “Under the current program standards, we believe that caution must be taken in attempting to make any connections between MIPS performance and physician quality, particularly in assessing the earliest years of MIPS performance data.”

MIPS Cost and Time Commitment Pose a Burden for Participants

Smaller practices paid $18,000 per year, but only received a 1.68% maximum bonus.

A recent study published in JAMA Health Forum suggests the time and financial costs of MIPS participation are considerable and, taking this into consideration, policymakers should find ways to reduce the administrative and financial burden for doctors to take part in this program.

The investigation was based on interviews with owners of 30 physician practices across the United States and found, on average, each physician spent $12 ,811 to participate in MIPS during 2019. Additionally, clinicians and administrators accrued more than 200 hours per physician on MIPS-related activities over this time period.

Small and medium primary care practices had mean per-physician costs of over $18,000. However, the return on investment may not be worth it. In 2020, for example, clinicians with a perfect MIPS score received a maximum positive payment adjustment of 1.68%, based on 2018 performance.

“It costs over $18,000 per doctor in administrative and time fees to participate, yet the maximum bonus was only 1.68%,” Dr. Michaels says. “Doctors are spending more than they are receiving in MIPS. To imply that there is some sort of a quality improvement by participating in MIPS is completely missing the obvious point that the system is still broken and needs improvement.”

MIPS is a major Medicare value-based purchasing program, influencing payment for more than one million clinicians annually. There is a growing concern that MIPS increases administrative burden, and little is known about what it costs physician practices to participate in the program, the researchers said.

Physician time accounted for the greatest proportion of overall MIPS-related costs. In 2019, physicians spent more than 53 hours per year on MIPS-related activities, which translates to nearly $7,000 per physician. If physicians see an average of four patients per hour, these 53 hours could be used to provide care for an additional 212 patients a year—equal to more than a full week’s work for a physician, the authors noted.

“The attention of policymakers may be warranted to reduce the burden of the MIPS program, particularly given the uncertainty regarding whether it improves quality or outcomes for patients,” they wrote in their paper.

Khullar D, Bond AM, O’Donnell E, et al. Time and financial costs for physician practices to participate in the Medicare merit-based incentive payment system, a qualitative study. JAMA Health Forum. May 14, 2021. [Epub ahead of print].


1. Sheth N, French DD, Tanna AP. Merit-based incentive payment system scores in ophthalmology and optometry. Ophthalmology. 2021;128(5):793-5.

2. AOA faults ophthalmology journal analysis of optometrist, ophthalmologist MIPS scores. American Optometric Association. www.aoa.org/news/practice-management/perfect-your-practice/aoa-faults-ophthalmology-journal-mips-study?sso=y. May 13, 2021. Accessed May 17, 2021.