- April 18, 2018
- ByMike Lipscomb
Currently, the Merit Based Incentive Program (MIPS) is the Centers for Medicare and Medicaid Services’ largest value-based care payment program. Now, in year two, MIPS has continued to transform the healthcare industry from fee-for-service to value-based payment. The program attempts to incentivize quality, over quantity, by adjusting payments for physicians based on quality and cost effectiveness.
Last year was seen as a transition year for many practices and physician groups participating in MIPS. In order to become an exceptional performer in 2018, physicians, both individually and as a group, must understand how MIPS is scored, the 2018 changes and why MIPS is so important.
Four performance categories make up MIPS – Quality, Improvement Activities, Advancing Care Information and Cost. Each category has its own requirements, weight and maximum point values.
Each practice is required to report six measures to CMS that best reflect the practice. The practice may include more than six, however, CMS will only take the top six performing measures. The measures to be reported are at the discretion of the group or individual practice. Providers may also report on a specialty measure set, which can include fewer than six measures.
Advancing Care Information (25%)
Hospital-based providers (for example, most Emergency Medicine, Hospital Medicine, Anesthesia, Radiology Providers) are exempt from the Advancing Care Information performance category. This 25 percent is re-allocated to the Quality performance category making that category 75 percent for hospital-based providers. Non-hospital based providers must use a certified electronic health record (EHR) and attest to use in day-to-day practice.
Improvement Activities (15%)
With over 100 measures to choose from, individual providers and provider groups must report on measures that show commitment to quality improvement. Examples include: reporting via a qualified registry, use of a drug database, patient care coordination, population management and beneficiary engagement.
Providers do not report anything in this category. CMS calculates two measures from submitted Medicare claims: Medicare Spending per Beneficiary and Total per Capita Costs. The Cost Category is an addition to MIPS in 2018.
What’s New in 2018?
In the 2018 performance period, the performance threshold increased from three points to 15 points to avoid negative adjustments in the payment year. This will likely increase in 2019 to more than the mean or median of the 2018 national average.
Payment adjustments also increased. In 2017, providers could earn a positive or negative adjustment up to 4%, which increased to +/- 5% in 2018. This is expected to increase year-after-year.
Several bonus points are available to help providers meet their thresholds or exceed beyond them, bringing them closer to being exceptional performers. Examples of the available bonus points are:
- Improvement from 2017 Performance Year: Up to 10 bonus points will be awarded toward the 2018 MIPS final score for all who demonstrate any improvement to the quality or cost category from the 2017 performance year.
- Complex Patients Bonus: Up to five bonus points will be automatically calculated by CMS through cross walking patients’ ICD-10 diagnoses to Hierarchical Condition Categories (HCC) which produces an average HCC risk score. To maximize the chances of receiving bonus points for complex patients, providers must select ICD-10 codes to the maximum level of specificity, and report any applicable secondary diagnoses to capture the full complexity of every patient visit.
- Small Practice Bonus: Any practice with 15 or fewer MIPS-eligible providers will receive five points towards the final score.
- Exceptional Performance Pool: If a group scores at or above the exceptional performance bonus threshold (EPBT), which is 70 points for 2018, then the exceptional bonus is applied in proportion to the amount by which the MIPS score exceeds the EPBT. CMS is allocating $500 million per year (through 2022) to this EPBT pool. To find out if you qualify, visit the QPP website.
Calculating Your Score
MIPS uses a unified scoring system that assigns each performance category a range of points. The system takes exceptional performance, exemptions, evaluation at the individual or group level, special circumstances and non-patient-facing MIPS eligible physicians into account. The performance category evaluation criteria is as follows:
- Quality is a maximum of 60-70 points depending on the group size. Each measure is worth one to ten points compared to benchmarks based on the previous year or historical data. Any measure not reported will receive zero points for that measure. Bonus points are available for EHR reporting, high-priority outcome measures and performance improvement between 2017-2018. There is a minimum of one point earned for all quality measures submitted. To find out the category score, calculate the sum of the points for each activity and divide by the highest potential score of 60 or 70 points, depending on the group size.
- Advancing Care Information is only scored for non-Hospital based physicians. This category has a maximum score of 100 points, with a base score of 50 points to be earned by reporting at least one use for each of the five required base measures. Ten additional performance points can be earned for each measure for a maximum of 90 additional points. There are 15 bonus points available in this category but the cap is set at 100 points total.
- Improvement Activities are high (20 points) and medium weight (ten points) with a maximum potential score of 40 points. Over 100 improvement activities are available to choose from.
- Cost is scored by assigning one to ten points for each applicable Cost measure based on performance benchmarks. Providers are evaluated on all measures in the category applicable to Medicare Part B claims. Providers or groups must meet the case minimum requirements for CMS to calculate the category score.
An example of how to a MIPS score is calculated:
A physician group performs well for each quality measure and scores 55 points. The group fulfills the Improvement Activities category resulting in 40 points. As the group is a hospital-based group, the Advancing Care Information portion is rolled into the Quality category. Through CMS’ calculations, the group receives 7 points in the cost category. The individual physician’s MIPS score is:
Why MIPS is Important
This final MIPS score is then compared across all other physician MIPS score and a final +/- adjustment is calculated to make it a budget-neutral program for CMS.
Understanding MIPS, the scoring system and how it can affect individual providers and groups is important for a number of reasons. MIPS and the shift towards value-based healthcare isn’t going to change anytime soon, but changes are being made to the program to benefit those reporting on MIPS measures.
There is a big financial impact that comes with MIPS reporting. As we’ve previously mentioned, providers can gain positive adjustments up to four percent but also lose up to four percent, which will only increase over the next several years. These adjustments follow the individual provider, wherever practicing, two years following the performance year. Depending on the group, these adjustments could be passed along to the individual.
Lastly, providers’ reputations can also be impacted due to their individual MIPS scores. CMS publishes an array of provider-identifiable performance measures through the Physician Compare website. This site is for consumers to browse and third-party physician rating websites to procure for free. As consumers spend more out-of-pocket for their healthcare, they are seeking more transparency into provider quality and the cost-value equation. A study found that 65% of consumers are aware of online physician rating sites and that 36% of consumers had used a ratings site at least once. Unlike direct Medicare reimbursement impacts, which can change year-to-year based on clinician performance, damage to a clinician’s online public reputation may take years to reverse. Conversely, consistently high performance scores and ratings can become a strategic advantage over local competitors.
At ApolloMD, our Quality team does their best to provide monthly updates and educational resources to our provider teams. We understand that education is the best practice for ensuring exceptional performance and strive to provide this to all of our team members. For any questions or comments, please email firstname.lastname@example.org.
Dr. Mike Lipscomb began practicing Emergency Medicine in 1997 as a Clinical Instructor for the University of Michigan. In 2000, he joined ApolloMD at WellStar North Fulton Hospital, becoming Medical Director of the department in 2005. Dr. Lipscomb has served on multiple committees at the hospital, most recently completing terms of Secretary Treasurer and Chief of Staff, and continues to serve on the Medical Executive Committee. In 2013, ApolloMD was excited to welcome Dr. Lipscomb to the corporate team to oversee clinical operations of hospitals in the Southeast. With extensive experience in optimizing emergency department flow, EMR use, and patient satisfaction, Dr. Lipscomb became Chief Quality Officer for ApolloMD in 2016. Dr. Lipscomb received his medical degree from The University of Texas Southwestern Medical Center at Dallas, and completed residency training in Emergency Medicine at The University of Michigan Medical School.
Laura Springer is a key member of the ApolloMD Quality Team acting as Director of Quality Reporting. She joined the ApolloMD team in 2015 as a Data Analyst. Laura’s expertise in SQL Server allowed her to analyze financial and reimbursement data resulting in increased visualization of reimbursement changes. Her dedication to project management, coupled with her quality reporting and technical background has allowed her to monitor and report on provider quality performance and be successful in intricate reporting quality data to CMS. Laura received her bachelor of science in health promotion with a minor in business from Auburn University.
As Director of Analytics and Data Science, Donal Harrison supports the ApolloMD Quality Team through his expertise in data mining and statistical analysis. Donal holds a Master’s degree in Experimental Psychology with a focus in Quantitative Methods from the University of West Florida, where he studied novel applications for linear and nonlinear models in fully- and semi-randomized block designs. Donal has since put his data science skills to use in areas ranging from credit scoring to anomaly detection and has received awards for his work on the use of unsupervised machine learning in post-hoc analysis. Joining ApolloMD in 2015, Donal has applied his expertise in Python, R, and SQL programming to develop high quality, reproducible analytics at the company, facility, and individual provider levels. He looks forward to continuing to leverage modern technologies in delivering actionable insights that foster success for the ApolloMD Quality Team and its partners.