MIPS: Merit-Based Incentive Payment System

On November 2, 2017, the Centers for Medicare and Medicaid Services (CMS) released the Final Rule CY 2018 Updates to the Quality Payment Program (QPP), accepting some of organized medicine’s requests for continued flexibility in 2018 reporting, but reversing several proposals that would have reduced burdens. In particular, ASRS is disappointed that CMS reversed the proposed data completeness threshold from 50% back to 60% and increased the weight of the cost performance category from the proposed 0% back to 10%. Further, ASRS is disappointed that CMS continues to interpret MACRA as requiring it to apply the MIPS payment adjustment to reimbursement for Part B drugs. ASRS will continue to fight against this. With two pathways to participate in the QPP, the Merit-Based Incentive Payment System (MIPS) or an alternative payment model (APM), almost all ASRS members will be MIPS participants.

MIPS Exclusions

Program exclusions continue to apply for physicians new to Medicare and those who bill below the “low-volume threshold,” now $90K in Part B allowed charges or 200 or fewer beneficiaries. 

If you choose not to participate in 2018, you will receive a negative 5% payment adjustment in 2020. This penalty will gradually increase to negative 9% by 2022. ASRS urges you to participate. Physicians who score at least 15 out of 100 total points will avoid the 5% penalty. Those with final scores above this “performance threshold” of 15 points may receive positive payment adjustments. Small practices would automatically receive a 5 point bonus making it easier to meet or exceed this threshold. 

Overview of MIPS

CMS rates MIPS participants in four performance categories, including, quality, advancing care information, improvement activities, and cost. The weights each category will contribute to the final score are depicted below.   

Performance Categories/Weight Contributing to Total Score

Performance Periods

The performance period for the quality and cost categories is the full year (January 1 - December 31, 2018). Physicians submit quality data and CMS collects cost data from claims. For the ACI and AI categories, the performance period remains a minimum of any continuous 90-day period or longer - up to the full year. MIPS performance data must be submitted by March 31 of the year following performance. 

 

2017

 

2018

 

Performance Category

Reporting Period

Reporting Requirements

Reporting Period

Reporting

Requirements

QUALITY

Minimum of 90 days up to full CY 2017

Report 6 quality measures including at least one outcome measure, If no outcome measures are available, one high-priority measure can be used.

Large practices are also scored on hospital re-admission measure. (CMS calculates automatically via claims)

 

Pick your pace -  report as little as 1 quality measure for 1 patient to avoid penalty

Full CY 2018

No change in reporting requirements

 

Continued flexible approach but increased participation (see chart below)

Data completeness

 

Report measures for

50% of Part B patients via claims, or 50% of all patients via EHR or registry, except Web Interface and CAHPS = 100%

 

Report measures for

60% of Part B patients via claims, or 60% of all patients via EHR or registry, except Web Interface and CAHPS = 100%; Same for 2019 reporting year

Scoring

 

Up to 60 total points (small practices) or 70 points (large practices including the cause readmission measure)

 

3-10 points for each measure - scored against a benchmark

 

3 pts for measures that:

1) don’t have a benchmark 2) don’t meet case minimum or

3) fail data completeness

 

Bonus for additional outcome /high-priority measures 2/1 extra point capped at 10% (must meet case minimum /data completeness)

 

Bonus for end-to-end electronic reporting up to 10%

 

No change EXCEPT

1 point for each measure that fails data completeness criteria (large practices only- small practices still receive 3 points)

Performance Category

Reporting Period

Reporting Requirements

Reporting Period

Reporting

Requirements

ADVANCING CARE INFORMATION

90 day period

Base score - 50 points if achieve 4 or 5 required measures  (depending on CEHRT year)

 

Performance score – up to 90 points for reporting on other measures; 10 additional points for reporting to certain registries

Optional for ASC or Hospital based physicians (75% covered services are ASC, inpatient or ER) CMS will determine based upon claims and Reweigh to 0%.

90 day period

Same

New exemption- Small Practice Hardship (or if CHERT decertified by ONC) – Apply to CMS by 12/31 reweight to 0%. CAN apply for 2017 reporting year 

Scoring

 

155 potential points – 100 points get full credit

Bonuses:

Up to 15 points –

5 - report to one or more public health or clinical data registries;

10 - attest to certain IAs using CEHRT

 

No change in general scoring methodology

Bonuses:

5 - report to additional registry(ies) not used for performance score.

10 - attest to certain IAs using CEHRT

New 10 - points if use only 2015 CEHRT

IMPROVEMENT ACTIVITIES (IA)

90 day period

Attest to IAs. Full credit requires completing 4 IAs of medium-weight or

2 IAs of high-weight

Small Practices attest to 2 IAs of medium weight or 1 IA of high-weight

 

Only one MIPS eligible clinician need perform the activity for a group TIN to receive credit.

90 day period

No change

Scoring

 

40 points for full credit. Each medium-weight IA = 10 pts; high-weight IAs = 20 pts

 

Small Practices –

Medium IAs = 20 pts;
High IAs = 40 pts

 

No change

COST

CY 2017

No reporting.

CMS calculates score on

Two measures:

- Total per Capital Costs for all attributed beneficiaries

- Medicare Spending per Beneficiary

CY 2018

No change

Scoring

 

CMS calculates scores based upon Medicare claims. Max 10 points each measure. Does not count towards MIPS score.

 

No change in scoring methodology but counts towards MIPS score

MIPS Scoring Details for CY 2018

The performance threshold score that is needed to receive a neutral to positive payment adjustment (i.e. no penalty) has increased from 3 points in 2017 to 15 points in 2018. A score below this threshold will result in a negative payment adjustment for all Medicare claims in 2020. The threshold can be met in a variety of ways (see below grid). Physicians who achieve a final score of 70 or higher will be eligible for an exceptional performance adjustment, funded from a pool of $500 million, applied on a linear scale so that higher scores receive a higher adjustment (from 0.5 to 10 percent). 

How will your 2018 MIPS participation choices impact your 2020 payment adjustment?

**Exceptional performance bonus pool is unaffected by budget neutrality. The adjustment for each clinician will depend on the scores and the number of clinicians receiving a score at 70 or higher, and is applied on a linear scale so that higher scores receive a higher adjustment (from 0.5 to 10 percent for scores from 70.00 to 100.00).

Bonus Points

  • Small practices (15 or fewer eligible clinicians) – 5 points added to final score if group members submit data on at least one performance category. This one-time bonus will be reassessed annually.
  • Medical Complexity – 1-5 points added to final score based on the medical complexity of patients treated. This one-time bonus will be reassessed annually.
  • Added to ACI score
    • 10 bonus points to participants who only use 2015-certified technology
    • 10 Bonus for using CEHRT to report one of the specified Improvement Activities
    • 10 points added to performance score for reporting to one or more public health agency or clinical data registry to meet a measure associated with the Public Health and Clinical Data Registry Reporting Objective public
    • Another 5 bonus points to total score for reporting to at least one additional public health agency or clinical data registry that is different from the agency(ies) or registry(ies) applied towards performance score. 

Improvement Scoring for Quality and Cost Performance Categories

  • Quality improvement scoring will be based on the rate of improvement and will be measured at the quality performance category level.  Up to 10 percentage points will be available.
  • Cost improvement scoring will be based on statistically significant changes at the measure level. Up to 1 percentage point would be available. 

ACI Category Hardship and Other Exemptions

CMS will reweight the ACI category to the Quality category, increasing it to 75% of the MIPS score for:

  • A significant hardship exception (no 5 year limit applied);
  • New significant hardship exception for small practices;
  • An exception for hospital-based MIPS eligible clinicians and ASC-based clinicians (retroactive to 2017 transition year); and
  • A new exception for MIPS eligible clinicians whose EHR was decertified.

Steps You Can Take Now:

  • Review your Quality and Resource Use Reports (QRUR) to determine whether you participated successfully in PQRS in 2016.
  • Decide which reporting mechanisms you will use for each performance category
  • Go to the CMS QPP Resource Library to identify measure specifications
  • Review and identify measures for reporting on quality, advancing care information and clinical practice improvement categories.
  • Continue to check this website for updates. 

Additional Resources

CMS

AMA and Speciality Society Resources 

How To

ASRS Advocacy Letters

Joint Advocacy Letters

Advocacy Timeline

CMS Releases 2018 Quality Payment Program Proposed Rule Jun 20, 2017   

CMS Makes Further Revisions to All-or-Nothing PQRS Methodology Jun 20, 2017

ASRS Offers Snapshot to Help Guide Your MACRA Participation in 2017 Nov 2, 2016 

AMA to Host MACRA Briefing Webinars Nov. 21 and Dec. 6 - Oct 26, 2016

CMS Posts MACRA Final Rule, Provides Flexible Options for Physicians - Oct 14, 2016    

ASRS Weighs in on MACRA With Comments to CMS - Jun 29, 2016

 ASRS Joins AMA in outlining 'Must Haves' for Successful MACRA Implementation - Jun 22, 2016

MACRA: Information and Tools for Transitioning Your Practice - Jun 15, 2016