2021 MIPS Payment Update

The Merit-based Incentive Payment System (MIPS), the largest physician value-based care payment program, is aimed at continuous improvement in quality and healthcare costs. Not the first of its kind, MIPS or similar quality-and-cost-related programs are here to stay.

The first few years of the MIPS program were dedicated ramp-up years which allowed for more familiarity with the program and its functions. During this time, the performance threshold to avoid a negative payment adjustment was low, meaning lower risks but also lower incentive values.

As the program has progressed, the risks and incentives have significantly increased from where we started four years ago. Physicians and APCs must understand the 2021 performance year thresholds, how to improve scores and what is on the horizon from CMS for continued success.

2021 Changes

We predict the 2021 performance year will be comparable to the 2020 performance year.

In the 2021 performance period, the performance threshold increased significantly from 45 points to 60 points to avoid negative adjustments in the payment year 2023. Beyond 2021, the threshold to avoid a negative payment adjustment is unknown as of now. Sources have released the new threshold could possibly be the average MIPS score in total, in effect removing a threshold to avoid penalty.

The risk for payment adjustments remain the same. Currently, CMS has not forecasted the percent payment adjustment past the 2021 performance year, which could remain the same at +/-9%.

A deeper understanding of the program and awareness of where changes can be made to increase scores and performance is critical.

How to Improve MIPS Score

MIPS is made up of four categories  Quality, Promoting Interoperability, Improvement Activities and Cost. Each category has different requirements, weight and maximum point values. However, Quality is the category where individual clinicians have the most control. For hospital-based providers (like Emergency Medicine, Hospital Medicine, Anesthesia and Radiology), the Quality category also holds the most weight at 65% of the overall MIPS score, which makes it critical to score well.

While the other categories are important, physicians and APCs can work towards improving Quality scores with these simple tips:

1. Know the measures.

The first step in driving improvement efforts is to know what measures are tracked and reported. CMS requires group and individual practices to report on at least six measures.

2. Understand the requirements.

Each measure has a set of requirements to first be considered eligible for the measure and then for the measure to be considered met. Know which patients are included or excluded from the measure. Use accurate verbiage in documentation.

Make sure to meet the proper requirements of the measure. For example, in some cases it may require documenting why a test was ordered. Other requirement examples could include ordering a test, or not giving an antibiotic to a particular patient. Education is key when it comes to performing well in the Quality category.

CMS provides measure specifications for each program-eligible measure. All measure specification documents are available online. The specifications give full details of each individual measure and requirements to meet the measure.

3. Use data to drive improvement efforts.

CMS releases the national average and benchmarks for the individual measures at the beginning of each year. Use these scores as guides to compare how an individual or group is performing. Setting a goal based on the national average will also help drive improvement efforts. The CMS 2021 quality benchmarks and national averages are available in the QPP Resource Library using the search term “benchmarks.”

On the Horizon

CMS finalized a program called the MIPS Value Program (MVP) in the 2020 Physician Fee Schedule final rule. It intends to transform the MIPS program into one that engages clinicians and specialty societies to craft measures which assess physicians and other clinicians on outcomes. This framework is part of the Meaningful Measures initiative. The original plan suggest the MVP framework would be effective in 2021, but as with many delays related to the COVID-19 pandemic, sources predict this will be postponed until at least the 2022 performance year.

MVP will focus on the current MIPS categories while also connecting measures and activities across the Quality, Cost and Improvement Activities categories. Initially, the framework includes a uniform set of Promoting Interoperability measures to be included in all pathways. The MVP would be organized around a specialty, specific episode of care or health condition. CMS is working with specialty societies to design MVPs and will formally implement the pathways through rulemaking.

At ApolloMD, we understand education is the best practice for ensuring exceptional performance and strive to provide updated resources and information to all team members. Click here to download the 2021 Emergency Medicine MIPS cheat sheet. 

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