Explaining MIPS, the Merit-Based Incentive Payment System

Each performance year, CMS sets a “performance threshold” (PT) which is the number of points at which a provider receives 0% adjustment to their Medicare Part B payments.  If, just for the sake of illustration, the PT threshold is 50 points, then a provider earning 50 points will get 0% payment adjustment. That means that a provider can expect to be paid what they bill in Medicare covered professional services. However, providers earning more than 50 points would earn an incentive and providers with less than 50 points would be assessed a penalty.  The maximum base payment adjustment could be as much as a 27% increase (9% x 3.0), meaning a provider with a very high MIPS score could see a bonus payment of more than a quarter of their total Medicare part B billed services. However, in addition to the base payment adjustment, eligible professionals who exceed the 25th percentile of all MIPS scores above the PT are eligible for an additional “exceptional performance bonus” of up to 10%.  In total, those very high performing providers will be looking at a possible 37% increase in their Medicare revenue. The worst performers will see as much as a 9% decrease (penalty). Low scoring providers can get credit for improving their scores in the quality and cost categories from one year to the next, even if the new scores are still low compared to peers. This is a zero sum game. The program is budget neutral which means that the money available for incentives comes from the money assessed as penalties. That is what makes it possible for a few clinicians to earn a much higher percentage of their income as a bonus because, frankly, a larger pool of clinicians will experience penalties. Participants in alternative payment models like Accountable Care Organizations are exempt from this program. There are other EPs who, for various reasons won’t be subject to MIPS right now, but I am skipping the fine print.

It is important to remember that each eligible professional’s MIPS score (and all the EPs quality performance data) will be available on the Physician Compare website.  Consumers will be able to see providers rated on a scale of 0 to 100, which also allows them to see how a clinician compares to their peers nationally.   Patients will be looking at these data and so will the private payers. Remember that not only will MIPS scores be reported, but the performance rates of individual quality measures. I have discussed the issue of public quality reporting before and why it is important that wound care clinicians report quality measures relevant to the practice of wound care, otherwise they will be judged in the public square on the basis of measures like blood pressure control. However, as a result of MIPS, reporting relevant quality measures has taken on a whole new level of importance as you will see when I explain the Quality and Resource Use Report below.

The new “clinical practice improvement” performance category is an interesting and evolving concept. CMS’ requested stakeholder input on this and the categories include: expanded practice access (e.g., same-day appointments), population management (e.g., monitoring population health), care coordination (e.g., telehealth), beneficiary engagement (e.g., self-management training), patient safety and practice assessment (e.g., use of clinical checklists), and participation in Alternative Payment Models (APMs).  The bill states that a MIPS eligible professional in a practice certified as a patient-centered medical home (PCHM) or “comparable specialty practice” shall be given the maximum score of 15 for the practice improvement category.  Or, if the provider participates in an APM, then the minimum score will be 7.5 for this category. We will just have to keep an eye on this performance category since as the details are worked out.

The details are complex and it is easy to get lost in them, but the big picture is that a provider’s MIPS score can cause a rapid and profound change to a clinician’s revenue in either a positive or a negative direction. Wound care clinicians are poised to be hurt by this new plan because we care for complicated patients and may be mistaken for their primary care physician or attending surgeon, depending on board certification.  There is a way forward through the fog, as I will explain in the rest of this article.

Don’t hesitate to share your thoughts and/or questions on my blog.  Let’s keep this conversation going!

Next week, I’ll be writing about “The Quality Game Right Now: MU & PQRS.”

Remember to “Do the Right Thing!™”

Caroline Fife, MD

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