By Michael Marron-Stearns, MD, CPC, CFPC
(Editor’s Note: This article was modified from its original version on 1/9/2018 in order to update reimbursement figures with the most current available information.)
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provided the Centers for Medicare and Medicaid Services (CMS) with the legislative authority to create the CMS Quality Payment Program (QPP), which is made up of two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models. The 2018 QPP Final Rule was released on November 2, 2017 and CMS is referring to the 2018 performance year as “Quality Payment Program Year 2.”
Practices that have the goal of achieving high performance in the Merit-based Incentive Payment System (MIPS) will need to develop strategies related to performance in the Quality and—to a lesser degree—the Cost categories as quickly as possible. The reporting periods for these two categories start on January 1, 2018 and continue until December 31, 2018.
This brief online article will review selected aspects of MIPS with an emphasis on decisions that should be made in the near term. A more detailed review of 2018 QPP requirements and potential strategies will be published in the upcoming February 2018 issue of the Journal of AHIMA magazine.
Key considerations include:
- The Quality and Cost category performance period is a full calendar year in 2018. In 2017, practices could report for as few as 90 days and receive the maximum Quality performance score. The Advancing Care Information (ACI) and Improvement Activities performance periods remain at a minimum of 90 continuous days.
- The data completeness criteria for the Quality performance category has increased. The threshold has gone from 50 percent in 2017 to 60 percent in the 2018 (and 2019) performance years.
- MIPS performance category weightings have changed, and the Cost category is now weighted at 10 percent. Quality will be weighted at 50 percent, down from 60 percent in the 2017 performance year. The ACI category is weighted at 25 percent and the Improvement Activities category is weighted at 15 percent. Neither the ACI nor the Improvement Activity weightings changed in 2018.
- Performance thresholds will influence payment adjustments. The MIPS Performance Threshold that is used to determine negative, neutral, and positive payment adjustments has been raised from three points to 15 points for the 2018 performance period. The MIPS Additional Positive Payment Adjustment’s Performance Threshold for exceptional performance remains at 70 points. Practices that achieve a MIPS score of 70 or more points are eligible for positive payment adjustments drawn from a $500 million annual fund. The figure below provides an estimate of positive payment adjustments in 2020 based on MIPS scores achieved in 2018. MIPS scores of between 15 and 70 points will likely receive small positive payment adjustments of between 0.1 percent and 0.5 percent. Practices that reach a threshold of 70 points will receive an additional 0.5 percent positive payment adjustment through the additional payment adjustment. A MIPS score of 85 points is anticipated to result in a positive payment adjustment of approximately 1.5 percent, although the exact figure may be higher or lower depending on performance across the entire spectrum of MIPS participants. Practices that have a perfect score of 100 points may receive positive payment adjustments of approximately three percent. These payment adjustments will be applied to all allowable Medicare Part B charges submitted during calendar year 2020.
- The Cost category (10 percent weighting in 2018) will influence MIPS scores. For the 2018 performance period CMS will base cost performance on the Medicare Spending per Beneficiary (MSPB) and total per capita cost measures, when applicable. Cost measures are risk adjusted based on demographics and clinical conditions. This will place renewed emphasis on provider disease coding and supporting documentation. As noted previously, CMS will collect Cost data (through submitted claims) that will be used to assess performance between January 1, 2018 and December 31, 2018.
- The use of both the 2014 and 2015 Edition Certified EHR Technologies (CEHRT) will qualify for ACI category reporting in 2018. However, all practices will need to use 2015 CEHRT in 2019 (based on the current rule). Practices that use 2015 Edition CEHRT for a continuous 90-day or longer period in 2018 will receive a 10 percent bonus in the ACI category.
- CMS will award up to five bonus points for practices that care for complex patients. The determination of complexity will be based on the Hierarchal Condition Classification (HCC) coding and the percentage of dual eligible patients cared for by the practice.
- The criteria for exclusion from the MIPS have been modified. In the 2018 performance year CMS will exclude otherwise eligible clinicians and groups from the MIPS if they have more than $90,000 in Part B allowed charges or fewer than 201 Part B beneficiaries. These numbers are based on totals for the group and not on averages per clinician. Medicare raised these thresholds in an effort to reduce the burden on rural clinicians.
- A small practice bonus will be available for the 2018 performance year. Small practices, defined as groups of 15 or fewer eligible clinicians, will qualify for a small practice bonus of five points. This bonus is automatically assigned to small practices (i.e., there is no reporting requirement).
MIPS Strategies for 2018
Organizations that have the goal of achieving relatively high MIPS scores will need to quickly implement strategies that allow for high performance on quality measures in 2018. As detailed above, the quality reporting period starts on January 1, 2018 and the data completeness threshold is 60 percent of patients. This makes it unlikely that organizations that do not address measure performance early in the year will achieve high performance in the Quality category.
Steps that may be worth considering in the near term include carefully selecting measures based on a number of criteria including: clinical applicability, reporting requirements as detailed in the quality measure specification documents, an assessment of available reporting mechanisms, benchmarks, and—when available—performance in past years. Practices may wish to consider selecting more than six measures to track, allowing for some redundancy. CMS has stated they will use the six highest scoring measures to determine the final quality score.
Groups have found that successful implementation of quality performance strategies require education, workflow analysis and modifications, analytic capabilities, and ongoing monitoring. There is still time to implement these programs in early 2018 and achieve high performance in the MIPS.
2018 is an opportunity to prepare for MIPS performance in 2019, when the performance threshold may be as high as 80 points, making it much more difficult to avoid negative payment adjustments.
Dr. Michael Marron-Stearns (firstname.lastname@example.org) is CEO and founder of Apollo HIT, LLC.