Solutions for the Health Industry

We’re more than halfway through the second year of the Merit-based Incentive Payment System (MIPS), a quality payment program implemented by the Centers for Medicare and Medicaid Services (CMS). And there’s still plenty of time for your community specialty practice to improve patient care, avoid payment penalties and maximize your reimbursement.

Ninety-one percent of eligible clinicians participated in MIPS in 2017, the program’s first year, according to a recent CMS blog post by CMS administrator Seema Vermai. That slightly exceeded CMS’ goal of 90 percent.

If your specialty practice hopes to meet its goals this year, you need to be aware of important changes that CMS made to the MIPS program for 2018. By adapting to those changes, your practice will position itself to succeed this year and beyond.

Here are what I consider the five biggest changes this year and how your practice should respond.

1. Eligibility requirements
Quote from the author

CMS raised the MIPS eligibility requirements. That means fewer providers are required to participate. In 2017, clinicians who treated more than 100 Medicare patients and billed Medicare more than $30,000 a year for their care were required to participate. In 2018, CMS set the threshold at more than 200 patients and $90,000 per year. The levels apply to the same eligible clinicians: physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists.

What your practice should do: Check your eligibility status. If you weren’t eligible last year, you probably aren’t this year—unless there was a jump in the number of Medicare patients you see. That means your participation is voluntary again this year. If you were required to participate last year, you may not have to participate this year because of the higher thresholds. If you don’t have to participate this year, it’s up to you to continue. Remember, you can participate either as a group or as an individual clinician. If you’re an individual and want to continue to participate, you can join an eligible group. The group can be a formal practice with its own Taxpayer Identification Number. Or, the group can be a “virtual” group of 10 or fewer eligible and unaffiliated clinicians.

2. Topped-out measures

Based on the 2017 results, CMS identified six quality measures as “topped out.” That means nearly all practices scored at or near 100 percent on these six measures. Under CMS’ scoring system, a practice can earn a maximum of seven points toward its final MIPS score on a topped-out measure, rather than the maximum of 10 points on a measure that’s not topped out. Two of the six measures apply to surgical practices, two to radiology, one to pulmonary medicine and one to dermatology. CMS cited the topped-out measures and affected specialties in its overview of the final 2018 rules.ii

What your practice should do: Check to see if the topped-out quality measures apply to your practice. If they do, and you were planning to use them again this year, you should consider swapping them out for other quality measures that apply to your practice. Your top score on any new quality measure won’t be limited to seven. And, it still will be possible to earn a max of 10 points toward your final MIPS score.

3. Raised quality benchmarks

Eligible practices must choose six quality measures out of more than 270 different measures to submit to CMS. The collective score on each of the six measures counts toward 50 percent of your final MIPS score. That’s down from 60 percent in 2017. There are three types of quality measures: process measures, outcome measures and high-priority measures. Each metric has a national benchmark that goes up as more providers get good at meeting it. The national benchmark rose on a majority of the quality measures this year, making them harder to meet.

What your practice should do: Your practice’s quality measure benchmarks are likely going up, too. You need to monitor your benchmarks. CMS adjusts benchmarks at the beginning of the year, as well as throughout the year. If you’re performing at the same level as you did in 2017, you probably won’t get the same number of points as you did last year.

You have a few options. One: You can make changes in your practice to get better and hit the new benchmark. Two: You can earn bonus points for showing improvement year-to-year even if you fall short of the new benchmark. Or three: You can submit as many measures as possible that apply to your practice. Don’t limit yourself to six. Specifically, you can earn extra points by submitting additional outcome and high-priority measures.

Key Changes to MIPS in 20184. Emphasis on quality

Quality measures count toward 50 percent of a provider’s final MIPS score this year. CMS divided the other 50 percent into three categories for 2018:

  • Promoting interoperability (25 percent)
  • Improvement activities (15 percent)
  • Cost (10 percent)

Under the Medicare Access and CHIP Reauthorization Act (MACRA), which created the MIPS program, the cost category counted for 0 percent in 2017, 10 percent this year and was going to jump to 30 percent in 2019. But Congress tapped the brakes on costs when it passed the Bipartisan Budget Act in February. Now, the cost category will gradually increase each year and not reach 30 percent until 2022. That means quality measures will continue to be the largest component of a provider’s final MIPS score for at least the next three years.

What your practice should do: That means two things for your practice. First, you should continue to focus on quality measures, as they will continue to be the biggest influence on your final MIPS score. Don’t rely on the other three categories to carry your final score for the time being. You need to look at your patient population and the acuity of your patient population. Use both cues, or qualitative data, and clues, or quantitative data, to improve the care that you provide. Second, if you don’t have one already, you need to develop a strategy to reduce costs. And you’ll need to have that plan in place by 2021 as the weight of cost measures jumps to 30 percent the following year.

5. Higher thresholds, bigger penalties

Practices that have a final MIPS score this year of 15 or less out of a possible 100 will have their Medicare payments reduced by up to 5 percent in 2020. (There’s a two-year gap between performance and payment adjustments.) That’s up from the penalty threshold last year. Practices that had a final MIPS score in 2017 of three or less will have their Medicare payments reduced by up to 4 percent in 2019. By 2022, the threshold will be 50. That means a practice with less than a 50 final MIPS score will face a payment penalty. And the penalty will be as much as a 9 percent reduction in payments.

What your practice should do: CMS designed MIPS to get harder over time. National benchmarks are higher and more difficult to achieve. And soon, cost will decide nearly one-third of your final MIPS score. In addition to tracking national benchmarks, poring over your data for improvement opportunities and developing a cost-reduction strategy, your practice should look to earn extra points from CMS. CMS created a number of opportunities for practices to do this. Those extra points may mean the difference between a payment penalty and a payment bonus. For example, this year you can earn up to five extra points for treating complex patients. You can earn up to five extra points for showing year-over-year improvement on a quality measure. And you can earn 10 extra points for using a certified EHR system.

In her blog post, Verma said CMS is committed to making changes to MIPS that will “continue to reduce burden, add flexibility and help clinicians spend less time on unnecessary requirements and more time with patients.”

The key to success is the last word in that quote: patients. If you keep patients top-of-mind as you work through all of the changes to MIPS, your practice will reap the financial and clinical benefits of this program. And ultimately, that means you will give better care to each patient who walks through your door.

Related: Learn more about McKesson’s MIPS services for specialty practices.

i"Quality Payment Program Exceeds Year 1 Participation Goal," CMS, 2018
ii"Quality Payment Program Year 2: Final Rule Overview", CMS

Linda DiBenedetto

About the author

Linda DiBenedetto is a practice advisor with McKesson Specialty Health's Innovative Practice Services. She supports specialty community-based practices with MIPS and OCM payer initiatives. Linda has years of experience in revenue cycle operations supporting oncology and specialty community practices. She holds an AS degree in Health Information Management from Berkley College and graduated Phi Theta Kappa in 1998.

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