10 FAQs about the Merit-Based Incentive Payment System (MIPS)

10 FAQs About MIPS

Last updated January 2017

On October 14, 2016, CMS released the final rule for one of the most bipartisan and significant legislative changes to Medicare in a generation, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA repeals the Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula and replaces it with a new value-based reimbursement system called the Quality Payment Program (QPP). The QPP consists of two major tracks:

CMS predicts that 600,000 Part B clinicians will be subject to MIPS, as MIPS is effectively the “new default” for Part B where few clinicians are exempt from MIPS except under a few conditions.

Read on for some of the most frequently asked questions about MIPS, such as how MIPS impacts the management and reporting of performance measures inherited from Meaningful Use (MU), the Physician Quality Reporting System (PQRS), and the Value-Based Modifier (VBM). MIPS consolidates and strengthens the financial impacts of these programs, while leveraging their respective performance measures which have become increasingly familiar to clinicians over the last few years.

FAQs:

  1. What is MIPS?
  2. What are the financial and reputational impacts of MIPS?
  3. What is the timeline for MIPS?
  4. What is an Advanced Alternative Payment Model (Advanced APM) and its relationship to MIPS?
  5. What are the eligibility requirements and exemptions for MIPS?
  6. What are the MIPS performance categories and how are they scored?
  7. How does MIPS impact Meaningful Use?
  8. How does MIPS impact PQRS and the Value-Based Modifier?
  9. What are MIPS data submission requirements?
  10. What are five things to do now to prepare to implement MIPS?

 

1. What is MIPS?

The Quality Payment Program combines the existing Medicare Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value-Based Modifier (VBM) programs into MIPS, starting with the CY2017 performance year. MIPS payment adjustments are applied to Medicare Part B payments two years after the performance year, with CY2019 being the payment adjustment year for the CY2017 performance year.

MIPS defines four categories of eligible clinician performance, contributing to an annual MIPS final score of up to 100 points (relative weights are indicated for the CY2017 performance year and associated CY2019 payment year):

  • Quality (60% for 2017)
  • Advancing Care Information (ACI, renamed from Meaningful Use) (25% for 2017)
  • Clinical Practice Improvement Activities (CPIA) (15% for 2017)
  • Resource Use (0% for 2017, but will be weighted for 2018 and beyond)

The final score earned by a clinician for a given performance year then determines MIPS payment adjustments in the second calendar year after the performance year. Each clinician’s annual final score will be released to the public by CMS.

Although MIPS inherits much from the MU, PQRS, and VBM programs, historical high performance or penalty avoidance under the existing programs does not guarantee the same under MIPS. Read on to explore how MIPS specifically impacts performance management and reporting.

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2. What are the financial and reputational impacts of MIPS?

Financial Impacts

MACRA defines two types of financial impacts for clinicians participating in MIPS:

  • A small, annual inflationary adjustment to the Part B fee schedule
  • MIPS value-based payment adjustments (incentives or penalties) based on the MIPS 100-point final score

The inflationary adjustment is an annual +0.5% increase for the payment years CY2016 to CY2019, which is the first payment year for MIPS under the QPP. The inflationary adjustment resumes in CY2026 and thereafter with MIPS eligible clinicians receiving a +0.25% annual adjustment.

The potential MIPS incentives and penalties via value-based payment adjustments are much more substantial than the inflationary adjustments, so that’s what we focus on in this FAQ.

This table shows how the final score could result in value-based incentives reaching 37% of Medicare Part B payments by the fourth year of the program, while maximum penalties grow to 9%:

CMS budget-neutral program: incentives funded by penalties

Program Performance Year Medicare Part B Payment Adjustment Year Maximum -% Medicare Part B Payment Adjustment Maximum +% Medicare Part B Payment Adjustment
PQRS/VBM 2016 2018 -4% penalty +4%*X incentive
MIPS 2017 2019 -4% penalty +4%*X incentive
MIPS 2018 2020 -5% penalty +5%*X incentive
MIPS 2019 2021 -7% penalty +7%*X incentive
MIPS 2020 2022 -9% penalty +9%*X incentive
  • Precedence: 2014 PQRS/VBM, X=16 (not capped), resulting in a 32% max incentive
  • For MIPS, X capped at 3.0 plus a 10% "exceptional performance bonus"
    • For Performance Year 2020, up to 9% x 3.0 + 10% = 37% bonus

To ease the transition for the 2017 performance year, there are varying levels for organizations to either participate, or alternatively, be exempt from MIPS. Here is a brief summary of the options:

  • No participation: Organizations not exempt from MIPS that do not send in any 2017 data will receive a negative 4% payment adjustment.
  • Submit something: Reporting only one Quality, ACI or IA measure will earn enough MIPS points to avoid a penalty.
  • Submit a partial year: If you submit 90 days of 2017 data to Medicare, you may earn a neutral or positive payment adjustment.
  • Submit a full year: If you submit a full year of 2017 data to Medicare, you may earn a positive payment adjustment.
  • Participate in an Advanced APM: Organizations that sufficiently participate through an Advanced APM earn a 5% Part B bonus and are exempt from MIPS.

For each performance year (say CY2018, corresponding to the CY2020 payment year), CMS sets a performance threshold (PT) number of points at which providers earning PT points receive a 0% adjustment to their Medicare Part B payments. Each incremental point that a provider earns above the PT results in progressively higher incentives, whereas for each point the final score is below the threshold, the clinician is assessed a proportional penalty until a floor is reached. Consequently, very few eligible clinicians will experience a zero payment adjustment, which greatly escalates the level of competition among clinicians and their need for a rapid and effective improvement cycle. Essentially, every MIPS point translates directly into higher or lower reimbursement. For the 2018 performance year, if a clinician has a final score below 1/4 of the performance threshold, such as zero points, then the penalty assessed is 5%, the maximum penalty.

Should half of all MIPS eligible clinicians earn an incentive for the 2018 performance year and beyond, while the other half are assessed a penalty, then the budget neutrality factor, X, would be approximately 1.0 for the CY2018 performance year if both sets of clinicians bill about the same amount of Part B payments. That would result in a maximum base incentive of 5% x 1.0 = 5% for achieving a final score of 100. However, there is an additional exceptional performance bonus that escalates up to 10% for progressively higher performers who exceed an exceptional performance threshold number of MIPS points. That means the sum of the maximum base incentive and exceptional performance bonus equals a maximum total upside potential of 5% + 10% = 15% for the CY2018 performance year. Therefore, the top-to-bottom MIPS potential impact on Part B payments for CY2018 may be from a 15% incentive down to a -5% penalty, or a total 20% top-to-bottom swing.

Theoretically, the budget-neutrality X factor could reach a capped-value of 3.0 should there be many more clinicians penalized than receiving incentives in a given year (precedence: X reached 16 for the 2014 PQRS/VBM performance year). So for the CY2018 performance year, the base adjustment could reach as high as 5% x 3.0 = 15%, resulting in an even higher maximum incentive of 15% base + 10% exceptional performance bonus = 25%. Similarly, the maximum possible incentive for the CY2020 performance year could reach 9% x 3.0 + 10% = 37%.

For 2017, CMS has set the performance threshold as 3 points and the exceptional performance threshold to 70 points in order to greatly reduce the chance of being penalized for low performance during the transition year. Starting in 2019, the performance threshold is determined annually as the mean or median of the MIPS scores for all eligible clinicians in a prior period selected by CMS. The performance threshold is expected to naturally increase year over year as average national peer performance improves and low performers potentially drop out of Medicare or MIPS entirely.

Reputational Impacts

CMS publishes an array of clinician-identifiable performance measures through its Physician Compare website 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 clinician 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.

The Quality Payment Program provisions address this consumer demand. MIPS will publish each eligible clinician’s annual final score and the scores for each MIPS performance category within approximately 12 months after the end of the relevant performance year. For the first time, consumers will be able to see their clinicians rated on a scale of 0 to 100 and how their clinicians compare to peers nationally. This level of transparency and specificity goes beyond existing programs such as VBM, which calculates quality and resource use scores but does not publicly publish the results.

In addition, all statistically significant measure values in the Quality and Advancing Care Information (ACI) categories for each clinician will be available for free download. Clinician activities reported for the Improvement Activities (IA) category will be listed for every clinician. Cost will be reported for 2018. Physician Compare will also continue to publish cost utilization data for all Medicare Part B clinicians.

MIPS Score Follows Clinicians Who Switch Organizations

CMS binds the MIPS score to the clinician for each performance year, so that if the clinician changes organizations before the associated payment year (two years after the performance year), the clinician brings along his or her MIPS score and the associated Part B payment adjustment to the new organization. This greatly impacts physician recruiting, credentialing, contracting, and compensation plans. Each MIPS score thereby becomes a central and inextricable part of a clinician’s profile and public reputation for the succeeding two years after that score is earned.

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3. What is the timeline for MIPS?

The timeline for the MIPS rulemaking process leading up to the launch of the program on January 1, 2017:

  • April 27, 2016 – CMS released proposed MACRA rule containing MIPS regulations
  • October 14, 2016 – MACRA final rule published, clarifying the Quality Payment Program
  • January 1, 2017 – First MIPS performance year begins

For MIPS, clinician performance data for the Advancing Care Information, Quality, and Improvement Activities categories for a performance year are generally due to CMS by March 31st of the following calendar year.

There is no official end date to MIPS, so the potential financial impacts continue as described above indefinitely.

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4. What is an Advanced Alternative Payment Model (Advanced APM) and its relationship to MIPS?

Clinicians in entities sufficiently participating in Advanced APMs are exempt from MIPS. In order to understand Advanced APMs, you must first understand how MACRA defines an alternative payment model (APM), of which Advanced APM is a subclass. Strictly speaking, an APM includes only these payment models run by CMS (not by commercial payers):

  • CMS Innovation Center Model (other than a Health Care Innovation Award)
  • Medicare Shared Savings Program Accountable Care Organizations (MSSP ACOs)
  • Demonstration under the Health Care Quality Demonstration Program
  • Demonstration required by federal law

There are also other payer Advanced APMs, which can be run by commercial payers and play only a restricted role within the Quality Payment Program. Other than this one exception, the term APM should be understood as only certain Medicare payment models.

The subset of APMs known as Advanced APMs must fulfill these additional requirements:

  • Requires participants to use certified EHR technology
  • Bases payment on quality measures comparable to those in the MIPS Quality performance category
  • Either APM entities must bear more than nominal financial risk for monetary losses or the APM is a Medical Home Model expanded by the CMS Innovation Center

The QPP lists the following CMS programs as Advanced APMs:

  • Medicare Shared Savings Program (two-sided models: Tracks 2 and 3)
  • Next Generation ACO Model
  • Comprehensive ESRD Care (CEC) (large dialysis organization arrangement)
  • Comprehensive Primary Care Plus (CPC+)
  • Oncology Care Model (OCM) (two-sided risk track available in 2018)

Clinicians in entities sufficiently participating in Advanced APMs will also receive an annual 5% Medicare Part B bonus, as described further in the APM FAQs.

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5. What are the eligibility requirements and exemptions for MIPS?

The eligibility net for MIPS expands over the first several years as follows:

  • CY2017 and CY2018 performance years: Physicians (MD/DO and DMD/DDS), Physician Assistants, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists
  • CY2019+ performance years: Expanded to physical and occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dietitians/nutritional professionals
  • Only those eligible clinicians in the categories above who bill for Medicare Part B (otherwise known as the Physician Fee Schedule) or Critical Access Hospital (CAH) Method II payments assigned to the CAH
    • Excluded from MIPS payment adjustments: Payments from Medicare Part A, Medicare Advantage Part C, Medicare Part D, FQHC, or Rural Health Clinic facility payments billed under all-inclusive payment methodologies and CAH Method I facility payments

Exemptions from MIPS

For the CY2017 performance year, there are only three exemptions from MIPS for clinicians who otherwise meet the eligibility requirements above:

  • Clinicians in their first year of Medicare Part B participation
  • Clinicians billing Medicare Part B up to $30,000 in allowed charges or providing care for up to 100 Part B patients in one year
  • Clinicians in entities sufficiently participating in an Advanced APM (see the APM FAQs for more information) for which either:
    • The collective Part B payments for services delivered by the Advanced APM entity’s clinicians to patients attributed to the entity is at least 25% of the payments for services delivered by the entity’s clinicians to all patients who could, but may not, be attributable to the entity (“attribution-eligible”)
    • The collective number of patients who receive services delivered by the Advanced APM’s clinicians and who are attributed to the Advanced APM is at least 20% of the number of all patients who are attribution-eligible and received services delivered by the Advanced APM’s clinicians

Note that clinicians may choose to either be rated on an individual-clinician basis or as a group of clinicians billing through a common tax ID. Hence, the preceding references to “clinician” in this eligibility section also hold true if “clinician” is replaced with a “group of clinicians billing through a common tax ID.”

MIPS APM Clinicians

Confusingly but perhaps inevitably, there are clinicians who not only belong to an Advanced APM or a non-Advanced APM, but are also subject to MIPS. For example, Advanced APM clinicians not meeting either minimum thresholds as noted in the bullet points above are also subject to MIPS. The QPP defines special scoring and data submission rules governing a subclass of such clinicians who are called MIPS APM clinicians. A common example consists of clinicians who participate in a one-sided Track 1 Medicare Shared Savings Program ACO, which is a non-Advanced APM but for which MACRA provides provisions to ease MIPS reporting burdens and grant MIPS points for APM participation. For more on the special MIPS rules governing clinicians subject to both QPP tracks and meeting certain additional requirements to be deemed MIPS APM clinicians, see our APM FAQs.

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6. What are the MIPS performance categories and how are they scored?

As described above, there are four categories of MIPS eligible clinician performance contributing to a composite performance score of up to 100 points. For the CY2017 performance year (and associated CY2019 payment year), the relative category weightings are:

  • Quality (60% for 2017)
  • Advancing Care Information (ACI, renamed from Meaningful Use) (25% for 2017)
  • Improvement Activities (IA) (15% for 2017)
  • Cost (0% for 2017, but will be weighted for 2018 and beyond)

The relative weightings between the Quality and Cost categories change in subsequent years of the program. For the CY2019 performance year and beyond, each of these categories have 30% weightings. In addition, under certain allowable circumstances where clinician performance is unable to be determined for a given category or special rules apply, then MIPS sets that category’s weight to 0% and redistributes the weight to other categories as the MACRA rule specifies. In 2017, at least two categories must be rated for performance in order for the clinician to receive a final score. If a final score cannot be determined, then the clinician receives zero payment adjustment.

MIPS clinicians can choose to be rated on either an individual-clinician basis or as a group of clinicians (defined by a tax ID), with the constraint that the choice applies across all performance categories. A clinician’s achievable final score could be significantly impacted depending upon whether that clinician is rated individually or inherits the final score earned by an entire group. MIPS clinicians also participating in certain alternative payment models, such as Medicare Shared Savings Program ACOs, must be rated as a group of clinicians and do not have the choice to be rated as individuals for certain performance categories.

Each performance category is scored separately as a percentage of maximum possible performance within that category. Then the category-level scores are weighted as listed in the bulleted list above (for 2017) and then summed to produce the MIPS final score.

An important fact is that clinicians who have historically performed well under MU and avoided PQRS and VBM penalties may not yet have high enough MIPS ACI or Quality measure performance to avoid penalties in the long run. MIPS forces historically high performers to re-evaluate their performance status based on how the MIPS scoring system differs from those of MU, PQRS and VBM.

Quality

MIPS essentially adopts the quality measures and reporting methods from the PQRS and VBM programs. Although there are some changes to the PQRS reporting methods as described later, for the most part, the quality reporting methods remain the same.

Most clinicians must report up to six PQRS measures, across any combination of quality domains, where one measure is an outcome measure (or a high priority measure, if an outcome measure is unavailable). Groups using Web Interface must report 11 quality measures.

In addition to the six PQRS measures, CMS calculates one population measure for groups with 16 or more clinicians and a minimum of 200 cases. Groups below that threshold will not have a population measure included.

Each measure is assigned a possible 10 quality points so a total of 60-70 quality points are available, respectively, depending on the number of clinicians in the group being rated for MIPS. Each measure earns up to 10 points based upon the percentile-basis performance of that measure relative to national peer benchmarks.

For example, if a PQRS measure has a 62% measure performance rate that is better than 60% of peers reflected in the benchmark, then that measure would earn 7 out of 10 possible points, according to this illustrative measure benchmark table from the MACRA Final Rule:

Example of Using Benchmarks for a Single Measure to Assign Points

Decile Sample Quality Measure Benchmarks Possible Points
Decile 1 0 - 6.9% 1.0 - 1.9
Decile 2 7.0 - 15.9% 2.0 - 2.9
Decile 3 16.0 - 22.9% 3.0 - 3.9
Decile 4 23.0 - 35.9% 4.0 - 4.9
Decile 5 36.0 - 40.9% 5.0 - 5.9
Decile 6 41.0 - 61.9% 6.0 - 6.9
Decile 7 62.0 - 68.9% 7.0 - 7.9
Decile 8 69.0 - 78.9% 8.0 - 8.9
Decile 9 79.0 - 84.9% 9.0 - 9.9
Decile 10 85.0 - 100% 10

Note that tenths of points are possible. If a measure rate lies within a benchmark decile rather than on a decile boundary, then one would linearly interpolate the quality point value between the decile boundaries to derive the quality points to the nearest tenth of a point.

As an example, if all six measures earned seven points each, then the total points would be 6 x 7 = 42 out of a possible 60 points, or 42/60=70%. As the Quality category for the CY2017 performance year has a weight of 60%, then a quality score of 70% would result in the Quality category contributing 70% x 60% x 100 = 42 MIPS points to the clinician’s overall MIPS final score.

MIPS also provides additional paths to achieve a Quality score of 100% by granting bonus points for certain quality reporting activities. So if two bonus points were earned in the example immediately above, then the quality score would increase to (42+2)/60 = 73.3%, resulting in 44 MIPS points. Note that the bonus points are not counted in the Quality score denominator (we still divide by the 60-70 possible points from the 6-7 measures, not by 62 or 72 points), so it is possible to get a Quality score of greater than 100%, in which case the quality score is truncated back down to 100%.

Bonus points may be accrued as follows:

  • Up to 10% for submitting high priority measures: Organizations that include high priority measures in the measures they choose to submit can receive a bonus of 1-2 points per measure total up to 10% of the total denominator of the Quality score, e.g. 10% of 60 = 6 max bonus points in the example above.
  • Up to 10% for end-to-end electronic reporting: CMS is using the QPP to drive electronic reporting forward. Organizations that use end-to-end electronic reporting can achieve a bonus of 1 point for each measure totaling up to 10% of the possible performance points in the Quality category. Note that this bonus cap is a separate bonus cap from the high priority measures.

For the GPRO Web Interface quality reporting method where a greater number of preselected measures are used, the denominator of the quality score would be the number of measures x 10.

Advancing Care Information (ACI)

MIPS changes Meaningful Use (renamed to ACI) from an all-or-nothing compliance program to a continuous scoring system where MU measure rates are compared to benchmarks in much the same way as described for the MIPS Quality category immediately above.

For example, if a clinician in the existing MU program achieves a performance rate of 15% on an MU measure with a compliance threshold of 10%, then that clinician is just as compliant with MU as another who achieves a 90% rate on the same measure. However, under the ACI scoring system, the former will only earn 2 out of 10 performance points, whereas the latter will earn 10 out of 10 points, according to the decile measure scoring scale. This explains why a historically high MU achiever may end up having a low ACI score if MU performance rates do not improve.

The ACI category defines 131 ACI performance points that can be earned:

  • Base Score: 50 points for reporting either a non-zero numerator or a “yes,” as applies, for selected measures from the MU Modified Stage 2 or MU Stage 3 measure sets
  • Performance Score: Up to 90 points for performance on eight measures per the decile scoring scale described above
  • Bonus Points: Up to 15 bonus points for reporting to an additional public health registry and aligning with IA

The ACI percentage score is calculated by dividing the number of ACI points by 100 and capping the percentage at 100%, should more than 100 ACI points be earned. If fewer than 100 ACI points are earned, then the ACI performance decreases proportionally. For example, 50 ACI points equates to 50% ACI performance, resulting in 50% (ACI performance) x 25% (ACI category weight) x 100 = 12.5 CPS points contributed by ACI.

Improvement Activities (IA)

Under MIPS, clinicians need to either earn 20 points or 40 points, depending on their size and location.

  • MIPS eligible clinicians or groups that are small practices (15 or less clinicians), practices located in rural areas or geographic HPSAs, or non-patient facing need to earn 20 points to get full credit in the IA category.
  • All other MIPS-eligible clinicians need to earn 40 points to get full credit in the IA category.

To earn points, clinicians can:

  • Report any combination of medium-weight (worth 10 points each) and/or high-weight (worth 20 points each) activities, or
  • If a clinician participates in certain APMs, such as the Shared Savings Program Track 1 or the Oncology Care Model, the clinician earns 40 points (all future APMs under the APM scoring model will be assigned at least half credit), or
  • If a clinician is in other APMs, the clinician automatically earns half credit and may report additional activities to increase the score

The IA percentage score is calculated by dividing the total IA points by 20 or 40, respectively. Using a general MIPS clinician as an example, 30 points would yield a 30/40 = 75% IA performance score, which in turn would deliver 75% x (15% IA category weighting) x 100 = 11.3 MIPS points.

Resource Use

In 2017, the Resource Use weighting has been set to zero, but in 2018, that increases to 10%. MIPS rates clinicians for Resource Use (Medicare costs of attributed patients) based on 40+ cost measures to account for differences among specialties. There are no separate reporting requirements for clinicians, as the measures are calculated based on claims collected by CMS.

Example of Calculating a Final Score

Assuming that the numerical examples used for the four categories as described above all apply to the same clinician, we can calculate a total MIPS score from the components:

  • Quality = (42 of 60 points) x 60% weight x 100 = 42 points
  • ACI = (50 of 100 points) x 25% weight x 100 = 12.5 points
  • IA = (30 of 40 points) x 15% weight x 100 = 11.3 points (rounded up from 11.25)
  • Cost = (14 of 20 points) x 0% weight x 100 = 0  points
  • Total MIPS points = 42 + 12.5 + 11.3 + 0 = 65.8

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7. How does MIPS impact Meaningful Use?

First, MIPS does not impact the Medicaid Meaningful Use (MU) nor eligible hospital MU programs. In other words, for these programs, the MU Modified Stage 2 and Stage 3 measures and associated incentives and payment adjustments are not affected by MIPS nor the broader MACRA legislation.

MIPS impacts clinicians eligible for Medicare MU in the following ways:

  • Sunsets Medicare Part B payment adjustments and replaces them with MIPS payment adjustments where 25% of the MIPS Composite Performance Score is determined by the Advancing Care Information performance category, which is based upon MU Modified Stage 2 measures (for 2014 Edition CEHRT) and MU Stage 3 measures (for 2015 Edition CEHRT).
  • Moves away from all-or-nothing MU compliance based on measure thresholds to a hybrid scoring system for ACI where clinicians earn an all-or-nothing base score for reporting required measures, a continuous performance score for measure rate performance relative to a decile scale and a 5% bonus for reporting to more than one public health registry
  • Removes all measure exclusions defined under the MU program, as the hybrid scoring system for ACI is deemed to serve the same goal of providing clinicians flexibility in how to achieve high performance
  • Removes the requirement to report electronic clinical quality measures, as quality reporting is already addressed by the MIPS Quality category
  • Enables ACI to be reported either for individual clinicians or for a group of clinicians and through additional data submission methods beyond attestation, such as registry and EHR methods, previously reserved only for PQRS reporting
  • Requires that clinicians agree to cooperate with surveillance of CEHRT by ONC and to implement CEHRT in good faith such that no inhibition of health information exchange nor information blocking occurs

Note that some MIPS-eligible clinicians such as physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and hospital-based clinicians who were previously ineligible for MU will not be accountable for the ACI category so long as there are not sufficient ACI measures applicable to them. For such clinicians, the ACI weighting towards the MIPS CPS will be set to zero and redistributed to other MIPS performance categories.

Note that providers who have traditionally done well under all-or-nothing MU may not have good ACI scores. See our more detailed description of the ACI scoring system in question 5 to understand how it differs from how MU has historically been scored.

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8. How does MIPS impact PQRS and the Value-Based Modifier?

MACRA sunsets the standalone Physician Quality Reporting System (PQRS) and Value-Based Modifier (VBM) programs for applying Medicare Part B payment adjustments related to PQRS quality reporting and VBM quality and cost performance. However, the MIPS Quality performance category inherits aspects of the PQRS quality measures and reporting infrastructure created by the PQRS program and leveraged by the VBM quality measurement system as well. For example, the array of PQRS reporting methods, including registry, EHR, and web interface, are largely preserved for the purpose of reporting quality performance under MIPS. In addition, the MIPS Resource Use performance category largely mirrors the VBM resource use measurement system in terms of measures, patient attribution methodology and benchmarking.

On the other hand, there are some significant changes to how quality is reported and rated under MIPS versus the existing programs. The MIPS Quality performance category deviates from PQRS and the VBM quality measurement systems in the following ways:

Measure Selection

  • For the registry, EHR, and qualified clinical data registry (QCDR) reporting methods currently requiring nine measures and three quality domains, the minimum quality reporting requirement is reduced to only six measures and can span any combination of quality domains; however, the six measures must include one outcome measure.
  • A clinician may select six measures from a list of pre-defined “specialty measure sets” culled from the list of individual measures. Should a specialty measure set contain fewer than six measures, then a clinician could meet the minimum reporting requirement by reporting all the measures in the measure set.
  • MIPS broadens and revamps the Measure-Applicability Validation (MAV) process, which allows another means for clinicians to report fewer than the required six measures for the registry, EHR, and QCDR reporting methods.

Reporting Methods

  • For the registry and QCDR reporting methods, the “data completeness” standard, which defines the minimum subset of patients within a measure denominator that must be reported, is 50% of Medicare patients for 2017 and increases to 60% in 2018.
  • Clinicians intending to use the group practice reporting option (GPRO) (for clinicians choosing to be measured for MIPS performance as a group of clinicians) will only need to declare their specific reporting method by June 30th of the performance year if they choose the CMS Web Interface reporting method and/or choose to report patient experience measures via the CAHPS for MIPS survey (same as the current “CAHPS for PQRS”).
  • The PQRS registry measures group method (requiring reporting a minimum of 20 patients per measure) has been eliminated by the Quality Payment Program.

The data submission deadline for all reporting methods, except possibly the GPRO Web Interface method, is March 31st of the year after the performance year.

Quality Performance Scoring and Benchmarking

Each measure earns quality points based on a percentile scale versus benchmarks, e.g. a 55% measure rate may be greater than that of 60% of all clinicians, so the measure earns 7 out of a possible 10 points.

In order to derive the MIPS Quality points contributing to the clinician’s MIPS final score, add up the quality points across reported measures, divide by the maximum possible points to derive a quality score as a percentage, then multiply this quality score by 60 (for CY2017). The MACRA final rule contains some illustrative examples:

  • Bonus quality points are available for specific high-priority measures and for using CEHRT to report measures electronically end-to-end (note that a quality score > 100% due to bonus points still only yields a maximum 60-point quality contribution to the MIPS final score).
  • Each reporting method will have a different set of measure benchmarks for the measures reported through that method. The baseline period for deriving benchmarks will be two years prior to the performance year, which increases the likelihood that CMS will publish measure benchmarks prior to the start of the relevant performance year.
  • The VBM feedback report, or “QRUR,” will be replaced by a MIPS feedback report for clinicians to see how they scored for the performance year, but the report will likely still be delivered ~9 months after the performance year ends.

Essentially, the significant changes introduced by MIPS to how clinician quality performance is calculated and reported will force many clinicians to revise how they select PQRS reporting methods and measures, as well as how they monitor and predict quality performance.

Note that providers who have traditionally avoided PQRS/VBM penalties may not have a high enough MIPS Quality score to avoid MIPS penalties. See our more detailed description of the quality scoring system above in question 6 to understand how it differs from how PQRS/VBM has historically been scored.

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9. What are MIPS data submission requirements?

The Quality Payment Program intends to move clinicians towards using a single data submission method for multiple performance categories of MIPS. To support this, MIPS expands existing PQRS quality reporting methods, such as registry, EHR, and QCDR, to allow for reporting measures across the MIPS categories of Quality, ACI and IA. The Cost category is claims-based and thereby does not require clinicians to separately report cost information.

MIPS APM Clinicians

For a MIPS eligible clinician also participating in an APM and meeting certain additional requirements (a MIPS APM clinician), see the APM FAQs to learn about the related special rules governing MIPS data submission for such a clinician. For example, for a MIPS APM clinician, the MIPS Quality category may not require a separate data submission if the APM is already collecting quality data for CMS to analyze.

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10. What are five things to do now to prepare to implement MIPS?

  1. Educate your organization, particularly the C-suite, as soon as possible
  2. Estimate your MIPS score using your current MU, PQRS, and VBM scores
  3. Optimize MU & PQRS/VBM Quality to maximize the MIPS score (comprises 85% of the CY2017 MIPS score)
  4. Evaluate staff, resources, and organizational structure, e.g. combine MU and PQRS efforts under a single leader
  5. Identify CY2017 deadlines impacting CY2018 APM and/or MIPS participation, e.g. Medicare Shared Savings Program Track 2/3 ACO or NCQA PCMH application deadlines to gain MIPS exemptions or points

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