What the money is: nine percent, fifteen billion, and a diagnosis worth 0.39

Significant findings

Three streams of money run through a depression score.

The first is the clinician's. Under the 2015 MACRA statute, the Merit-based Incentive Payment System adjusts Medicare Part B payments by an "applicable percent": "for 2019, 4 percent; for 2020, 5 percent; for 2021, 7 percent; and for 2022 and" each year after, 9 percent, in both directions, with positive adjustments scaled by a factor that "may not exceed 3.0". CMS has "set the performance threshold at 75 points through the CY 2028 performance period"; score above it and the adjustment is positive, below it and it is negative. Measures 134 and 370 are among the quality measures that make up that score.

The second is the health plan's. MedPAC, Congress's advisory commission, wrote in March 2024 that "the current system for MA quality reporting and measurement is flawed and does not provide a reliable basis for evaluating quality across MA plans. Nonetheless, these measures are the basis for the MA quality bonus program (QBP), which uses trust fund and taxpayer dollars to increase MA payments by about $15 billion annually." Forty-two percent of contracts were in bonus status for 2024; roughly three-quarters of enrollees sit in plans rated four stars or higher. The Commission's wider finding: Medicare "spends an estimated 22 percent more for MA enrollees than it would spend if those beneficiaries were enrolled in FFS Medicare, a difference that translates into a projected $83 billion in 2024", and "MA plans' diagnostic coding practices increase payments and distort the goal of plans competing to improve quality".

The third is the diagnosis itself. Medicare Advantage plans are paid more for sicker enrollees, and a coded diagnosis raises the payment. In one CMS relative-factor table, the category "Major Depressive, Bipolar, and Paranoid Disorders" carried a factor of 0.388 for a community-dwelling, non-dual, aged enrollee, on a scale where the average person is 1.0. The HHS Inspector General found that "Diagnoses reported only on enrollees' HRAs and HRA-linked chart reviews, and not on any other 2022 service records, resulted in an estimated $7.5 billion in MA risk-adjusted payments for 2023", about two-thirds of it from in-home assessments; of its three recommendations, CMS agreed to one. In its 2024 model CMS reclassified the category: "Major Depressive, Bipolar, and Paranoid Disorders" became "HCC 155 Major Depression, Moderate or Severe, without Psychosis", under a stated principle that "Diagnoses that are particularly subject to intentional or unintentional discretionary coding variation or inappropriate coding by health plans/providers... should not increase cost predictions."

Worth asking

None of this means your clinician profits from your score, and nothing here supports a per-doctor figure; the money is program-level and mostly the plan's. It does mean a positive screen, a diagnosis code and a documented plan each carry a value to someone other than you. Knowing that is not cynicism. It is the context for asking what the plan is for.