Escalating Risk, Reward of the Merit-Based Incentive Payment System

MIPS is a sub-program under the CMS Quality Payment Program (QPP), which is designed to support the transition from fee-for-service federal payments into value or quality-based payments. The program went into effect in 2017 and is divided into the following categories:

• Quality
• Promoting interoperability
• Improvement activities
• Cost 

Providers receive a score in each of these categories to determine their overall MIPS score, and they receive a Medicare bonus payment (or penalty) based on their performance.

Like many other federal payment programs, the MIPS program began with easy-to-achieve benchmarks and minimal risk. However, escalating requirements have made the program more stringent over the past few years—with more changes planned through 2023.

Bigger financial downside and harder to achieve benchmarks are on the horizon for MIPS  

In its early years, the MIPS program included relatively little financial risk. But, starting in 2022, the performance threshold to receive a bonus payment will become harder to achieve and more providers will be forced to pay into the “penalty pool.” This “penalty pool” is used to fund MIPS bonus payments for those who achieve high scores. And, starting in 2022, this penalty could be as high as 9 percent of annual Medicare payments (a far jump from the initial 4 percent penalty risk in 2017).

But greater risk also creates more opportunity for those who can effectively manage their MIPS performance

“The stakes are getting higher with a lot more dollars at play,” explains Dr. Jason Adler, VP of Practice Improvement at Brault Practice Solutions. “But it’s important for provider groups to have a clear and deliberate MIPS strategy so that they’re not over burdening their providers or investing in excessive resources.”

Dr. Adler explains that there are three key areas that practice leaders should be focused on.

1. Determine your MIPS participation strategy

Some providers submit MIPS scores as part of their ACO, while others submit their MIPS scores separate from their ACO—and historically there’s been merit to either approach depending on your type of practice. But, starting in 2023 (or possibly 2022), some provider groups may want to take advantage of both strategies.

“There are two reasons why providers would want to put in this extra effort,” explains Dr. Adler. “First, because there will be more financial upside as the MIPS program matures. And, also because we expect high scores to become increasingly harder to achieve for those who submit as part of an ACO. So, provider groups can actually optimize their MIPS potential by submitting their data both ways.”

2. Select the right measures

Selecting the right measures is always key because, depending on your specialty, quality measures can account for up to 85 percent of your overall MIPS score.

“There are a few things to keep in mind when selecting your MIPS measures,” explains Dr. Adler. “You have to consider the hassle-factor. How much extra work will be required to achieve a high score for a specific measure? And does that extra work align with your current practice patterns? If the extra work becomes a hassle for your providers, then you probably won’t end up scoring well in that measure.”

Most providers have two choices of performance measures they can select from. They can select from the pre-published QPP measures, which are available to all providers. However, many of these measures create unnecessary work for physicians and can have unattractive benchmarks or other scoring limitations. Or they can contract with a Qualified Clinical Data Registry (QCDR), which generally offers more specialty-specific measures compared to the more generic options available from the QPP. 

Dr. Adler explains a quick reference point for selecting the right measures:

• Select measures that support your current practice patterns 
  Quality Managers should consult with the provider staff during the measure selection process. The best selections will generally be measures that do not generate additional work for providers. Measures that are consistent with a group’s common clinical practices largely reflect what providers already value and can support with consistent documentation. 
   
• Select measures with enough volume
  Your group must achieve at least 20 cases in order to receive a score on any specific measure.
   
• Do not select measures with artificial ceilings or unattractive benchmarks
  Some measures are so easy that CMS discourages their use by limiting the top score to seven (compared to 10 for other measures). Other measures might have a maximum score of ten if you achieve a perfect score but might also cut your score to a six if you’re one case shy of perfect. The ideal measure should allow you to achieve a reasonably high score, even if your performance on that measure is quite low. 

3. Understand your data

“In previous years, some providers could get away with only calculating their scores at the end of the year,” explains Dr. Adler. “This is when the program wasn’t very strict, so it wasn’t as important to stay on top of your numbers.”

But moving forward, Dr. Adler suggests that provider groups should be tracking their data at least monthly so that they can make course corrections as needed throughout the year.

“Group leaders should have frequent reporting at both the individual and group levels,” explains Dr. Adler. “Every failed measure shifts the curve. So, it’s important to aim for precision and accuracy across the entire practice.”

Frequent data review can also help provider groups identify any failure to capture data, coding inaccuracies, or other shortfalls.

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Article Contributors:

• Dr. Jason Adler
  VP President of Practice Improvement, Brault Practice Solutions
• Jay Fisher
  Partner, C3 Partners, LLC.

About Brault:

Brault is a revenue cycle and practice management organization that partners with hospitals and acute care physician groups. Their intelligent practice solutions include MIPS optimization, practice analytics, and provider documentation training. Learn more at www.Brault.us

About C3 Partners, LLC:

C3 Partners provides next-level MACRA Optimization through unique tools and powerful collaboration, as outlined in a clear Monthly MACRA blueprint.  See www.MACRAmonitor.com for more details.