Cassandra on MIPS Year Two

It’s Year Two. I can’t decide if that conjures up the image of primitive man making the second straight line on the wall of the cave, or Captain Kirk dictating into the ship’s log… probably the latter. It’s the second year of the Quality Payment Program (QPP) – established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The ship is headed to the undiscovered planet of Advanced Alternative Payment Models (AAPMs). That’s the destination which is not being discussed in wound care – but the ship is headed THERE.

On the way to the AAPM, 85% of wound care practitioners are subject to the Merit-based Incentive Payment System (MIPS). And CMS has promised that Year Two will be better because  . . . they have been “listening” and: the quality measures and activities are meaningful (even if they look the same as last year and not relevant to us), the clinical burden is minimized (even if some measures are harder to pass and take more documentation), and care coordination is better (I’ll let you know – I’m trying to get that solved for diabetic shoe paperwork and so far I can’t), AND – “clinicians have a clear way to participate in Advanced APMs.” (Yep – because that’s the destination.)

I will be blogging a lot about the specifics of MIPS Year Two, but today I’m focused on the big picture. It’s messy and it’s easy to get distracted. There are a lot of players on the field but the ball is moving, play by play, down the field in a specific direction.

In Year One, the Quality portion of MIPS was at 60%, but in Year Two, (which is referred to by CMS as the “2020 payment year” because that’s the year you actually experience your bonus or penalty) Quality counts as 50% of your total MIPS score. Next year in 2019, Quality will go down to only 30%. That fact is really important! Why? Because Quality is the segment of MIPS over which practitioners have the most individual control.

What does this mean? It means we are losing control over the way we get paid. Even though the quality measures seem silly and irrelevant to our actual specialty, at least we have been able to pick them. By next year, quality measures will account for less than a third of the total score that governs your MIPS penalty or bonus.

Last year CMS did not include Cost in its MIPS calculations. This year, the Cost portion of MIPS will count 10%. However, cost increases to 30% next year and beyond. CMS calculates Cost FOR you, using your Medicare claims data. Cost is based on how much money Medicare spends on your patients. This includes something you may not have heard of, “Medicare Spending per Beneficiary (MSPB),total per capita cost measures. Medicare is also creating 10 episode-based cost measures.  Medicare is making the transition to “episode of care” cost measures. The first few that they created did not go well, so they have gone back to the drawing board, but they are coming. They are making new ones. They say that they will be asking for input on them, so we had better be ready to provide it.


Here is the overall MIPS Equation:

[Quality Score] + [Cost] + [ACI which is using your EHR] + [Improvement Activities] = MIPS Score

Now see it another way- MIPS 2018:

[(QM)x 50%] + [(Medicare $$ Spending Per Beneficiary) x 10%] + [other stuff 35%] = 100% MIPS

Now see MIPS 2019:

[(Episode of care Quality Measures) x 30%] + [(MSBP) x 30%] + [other stuff 35%] = 100% MIPS

Now do you see WHY we can’t keep saying we heal 95% of wounds or even 70% of wounds? Do you see why we can’t say we do this in 16 weeks?

Do you see why we needed a risk stratification for wounds?

If we don’t start telling the truth about our patients, which is that they are chronically ill, we close about 50% of their wounds at best over about 6 to 8 months, and the rest stay in care forever because their wounds are a symptom of their underlying disease – then CMS will penalize our Part B payments. CMS will craft episode of care measures based on what we TOLD them happened to these patients (namely, that we healed 95% of them in a few weeks). Then they will look at the Medicare Spending Per Beneficiary which will be sky high and say we spend too much money on them.

We need a new, honest message. Patients are very sick. They have a lot of co-morbid conditions. We heal the ones we can. We use expensive therapies because they need them. We provide protocolized care.

You see what keeps me awake at night.

Do you know who Cassandra was in Greek mythology? She’s a tragic figure. She had the gift of being able to foresee the future. She was cursed because no one believed her. I don’t think it takes the gift of foresight to see this train coming, do you? There are things we can do to get ready. If you are a manufacturer of anything used for wound care—you need to be paying attention to this.