In 2016, the Centers for Medicare and Medicaid (CMS) introduced rules for a new program called Merit-based Incentive Payment System (MIPS). MIPS unified several of the previous CMS payment adjustment programs for eligible clinicians in Medicare into a single program, and MIPS created positive or negative Medicare reimbursement incentives based on specific categories to improve quality of care offered by clinicians.
MIPS went into effect in CY 2017 based on those initial rules, but CMS indicated they would be updating their respective rules each year. This whitepaper discussed the rules for MIPS taking affect in the CY 2018 performance year with a primary focus on its impact on health IT developers and EHR systems.
Eligibility and Payment Adjustments
For CY 2018, the list of which clinicians qualify as Eligible Clinicians (EC) remains unchanged. As in CY 2017, an EC is defined as a physician, a physician assistant, nurse practitioner, clinical nurse specialist or a certified registered nurse anesthetist.
CMS is changing the threshold value of number of Medicare patients seen and Medicare billing done during the performance year to qualify. In CY 2017, eligible ECs were excluded if their Medicare Part B billing was $30,000 or less or 100 or fewer Medicare Part B patients. For CY 2018, this threshold has been raised to $90,000 Medicare Part B charges or 200 or fewer Medicare Part B patients. This change will exclude more clinicians from MIPS reporting.
One notable change is the allowance for ECs to join “virtual groups” where ECs can partner with one another even if they are not billing from the same TIN. This can be beneficial for sole practitioners or small practices looking to collaborate with others, but it poses some potential challenges for Health IT developers as ECs must aggregate their data for measures and activities across the virtual group, and the ECs may look to their EHRs for assistance in this.
Scoring and Payment Adjustments
The scores of the different MIPS categories are pulled together to make a final MIPS Composite Score (MCS). Based on the MCS, ECs have their Medicare payment adjustment. Besides the individual category scores, CMS is also providing new bonus points options for small practices and for those caring for complex patients.
The MCS centers around a performance threshold. Those ECs scoring below the performance threshold will receive a negative payment adjustment based on a sliding scale, and those scoring above the performance threshold will receive a positive payment adjustment based on a sliding scale.
The payment adjustment sliding scale will range from -5% to +5%. The performance threshold moves from 3 points now to 15 points in CY 2018. ECs with a MCS between 0 and 3.75 receive the full -5% adjustment, and ECs scoring between 3.75 and 15 points receive a negative adjustment based on a sliding scale. As long as an EC scores 15 points on the MCS, there will be no negative payment adjustment. Scoring between 15 and 70 points results in a positive adjustment based on a sliding scale. As before, there is a high performance bonus for those scoring at 70 points or higher on the MCS. The rise in the MCS threshold requires ECs to submit additional MIPS category scores to avoid falling below the negative payment threshold.
Categories of MIPS
It should be noted that the weight percentages for the individual MIPS categories listed below are the standard and default values. There are some unique situations and scenarios that can cause their weights to be adjusted. Those scenarios are out of the scope of this whitepaper, and the CMS QPP resources should be consulted for those situations.
The Quality category addresses specific clinical quality measures to determine the healthcare provided for patients with specific ailments and healthcare scenarios. Before MACRA, CMS utilized the Physician Quality Reporting System (PQRS). With MIPS, PQRS is closed (CY 2016 being its last year) and the function moves into the Quality category of MIPS.
The weighting for Quality category will be 50%, with ECs submitting and being scored on up to six different quality measures. The performance period for Quality measures is a full calendar year, which is a change from the minimum 90 days in CY 2017. Based on the performance in that measure against the CMS posted benchmarks, ECs can typically receive 1 to 10 points for that measure as a result of their percentage results on a decile scoring system per measure. However, some mature measures are considered by CMS to be “topped out.” For those topped-out quality measures, CMS allows for a maximum of 7 points.
Also, if a measure does not meet data completeness requirements, the measure is limited to just 1 out of 10 points. In CY 2017, the minimum point floor was 3 points. Finally, bonus points also are available for improving your Quality category score in CY 2018 compared with CY 2017. This will encourage ECs to continue to improve their clinical care and persist in the same measures each year.
The Improvement Activities is probably the least changed of the categories. The scoring mechanisms of Improvement Activities scored as medium-weighted for 20 points or high-weighted for 40 points remain, as does the maximum category score of 40 points. The category itself remains weighted to 15% of the MIPS Composite Score. Bonus points remain if you use CEHRT to achieve certain activities. New and updated activities are listed in the CMS ruling and website.
Advancing Care Information
As indicated in the proposal, CMS is allowing ECs to use 2014 Edition CEHRT or 2015 Edition CEHRT for the Advancing Care Information (ACI) category. As a result, the ACI category in CY 2018 looks very similar to the category in CY 2017. ECs can still choose either the ACI measures or the ACI Transition measures. For either option, ACI category score is based on scoring in Base Measures, Performance Measures and Bonus points. The measures in the ACI category are unchanged except for a few clarifications of intent. The performance period is again a minimum of 90 consecutive days.
The EC still needs to complete only a minimal set of actions to satisfy the Base Measures and gain 50 percentage points. Also, greater success in the Performance Measures, i.e., high percentage score, results in higher points.
Bonus points are slightly changed. CMS still encourages use of 2015 Edition products by rewarding 10% bonus points for use of that edition vs. 2014 Edition. The only caveat for this bonus is that the EC must do ACI Measure activities and not those for ACI Transition Measures.
The bonus scoring methods has been slightly changed for the Public Health measures. In CY 2018, ECs are able to not report on Immunization Registry but instead substitute another public health measure and earn percentage points in the Performance Measure section. Then, additional engagement with other public health registries can earn bonus points. As before, EC can earn bonus points by completing certain Improvement Activities with their CEHRT.
For CY 2018, CMS decided to weight the Cost category to 10% as it was in CY 2017. The Cost category includes total per-capita cost for patients measure and the Medicare Spending per Beneficiary (MSPB) measure. Reporting of the Cost category was not required in CY 2017, but those who did had an option for achieving bonus points for improving their score. The performance period for Cost is a full calendar year. EHR systems are not directly involved or affected by the Cost category requirements.