Abstract:
Healthcare costs in the United States continue to grow at a rate that exceeds the annual GDP growth rate. As a result, healthcare costs continue to place an increasing burden on our national budget, and containing them has become a larger national priority. An increasing emphasis on improving value in the U.S. healthcare system has spurred an assortment of value-based and Alternative Payment Models (APMs) with great variability in requirements, penalties, and rewards. On April 16, 2015, the Medicare Access and Children’s Health Insurance Program Reauthorization Act was signed into law, bringing an end to the Sustainable Growth Rate era. Beginning in 2017, all clinicians who provide Medicare Part B services will have to choose to participate in one of two new reimbursement models: the Merit-Based Incentive Payment System (MIPS) or APMs. With such widespread change and important ramifications, it is important for physicians to have a basic understanding of how they will be affected. We provide a review of the current MIPS model.
Healthcare Costs
Healthcare costs in the United States continue to grow at a rate greater than that of the annual GDP. As a result, healthcare costs continue to place an increasing burden on our national budget, and containing them has become a growing national priority. Since 2015, there has been an increasing emphasis on improving value in the U.S. healthcare system, which has spurred an assortment of value-based and Alternative Payment Models (APMs) with great variability in requirements, penalties, and rewards. On April 16, 2015, the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) was signed into law, bringing an end to the Sustainable Growth Rate era.(1) Beginning in 2017, all clinicians who provide Medicare Part B services will have to choose to participate in one of two new reimbursement models: the Merit-Based Incentive Payment System (MIPS) or APMs.(2) The U.S. Department of Health and Human Services has set a goal of tying 50% of Medicare reimbursements to APMs by 2018, with 90% of remaining fee-for-service payments tied to quality or value.(3) Approximately 80% of physicians will not qualify for APMs and will default into MIPS, with 90% of those eligible physicians predicted to participate in it. With such widespread change and its important ramifications, it is important for physicians to have a basic understanding of how they will be affected. We provide a review of the current MIPS model.
Merit-Based Incentive Payment System
MIPS attempts to look at both quality and cost measures within its payment model. Its targets are based on relative performance. It rewards both improvements and achievements across quality measures and offers both penalties and bonuses (up to 9%) based on performance standards.(4) MIPS offers a pool of $500 million for bonuses to be paid between 2019 and 2024 to providers who perform exceptionally well,(1,5) with the rewards and penalties steadily increasing from a maximum of 4% percent in 2019 to 9% in 2022.(4)
The law bases the composite performance score on four components: quality; resource use; advancing care information (now known as promoting interoperability); and clinical practice improvement activity. Quality is one of the larger components, at 50% in 2019 and falling to 30% in 2021.(6) As part of the quality assessment, physicians will be required to report on at least six quality measures, including one outcomes measure from an annually updated inventory.(4) This will allow individual MIPS clinicians and groups to select the most meaningful quality measures for their individual practices and provide flexibility in reporting them. Resource use will start off as 10% in 2018, increasing to 30% in 2019.(4) Resource use will be calculated by the CMS using claims including two general measures: (1) Medicare spending per beneficiary; and (2) total per capital cost.(4) This category was designed to create an incentive for physicians to optimize resource expenditure while maintaining quality patient care. The promoting interoperability category, which will stay stable at 25%, attempts to replace the Meaningful Use measure on health information technology, with fewer and more flexible reporting requirements intended to be more representative of interoperability and data flow relevant to a physician’s practice versus electronic health capabilities alone. The clinical practice improvement activity component will stay stable, at 15%, and will reward physicians who have a wide range of practice-level activities, such as delivery of telehealth services, participation in registries, and provision of 24/7 access, which is intended to encourage behaviors that coordinate care across transitions and settings of care.
Several changes affecting the various MIPS categories in 2018 have recently been released. In the quality category, certain quality measures have had such high performance across the board that they are considered “topped out.”(7) This means that even if a practice submits a performance rate of 100 on that particular measure, the practice can still only earn a maximum of 7 out of the 10 possible points.(7) To benefit maximally from the quality category, practices would be wise to choose measures that are not considered topped out when picking what to be evaluated on.
Several performance measures have been added to this category,(7) including the following:
Perioperative care: selection of prophylactic antibiotic—first- or second-generation cephalosporin (Measure 21);
Melanoma: overutilization of imaging studies in melanoma (Measure 224);
Perioperative care: venous thromboembolism (VTE) prophylaxis (when indicated in all patients (Measure 23);
Image confirmation of successful excision of image-localized breast lesion (Measure 262);
Optimizing patient exposure to ionizing radiation: utilization of a standardized nomenclature for computed tomography (CT) imaging description (Measure 359); and
Chronic obstructive pulmonary disease (COPD): inhaled bronchodilator therapy (Measure 52).
Starting in 2018, CMS will calculate cost measures using claims data at the level of the taxpayer identification number (TIN) or National Provider Identifier (NPI) of the provider or group. The type most applicable to primary care is based on the risk-adjusted total cost of Medicare claims of patients attributed to a given provider or TIN. Physicians can report to MIPS through a few different options: as an individual, as a group, or both. An individual is defined as a single clinician, identified by his or her individual NPI tied to a single TIN. If you report only as an individual, you will report measures and activities for the practice(s)/TIN(s) under which you are MIPS-eligible and be assessed across all four performance categories at the individual level. Your payment adjustment will be based on your final score derived from the four MIPS performance categories.(8)
A group is defined as a single TIN with two or more clinicians (at least one clinician within the group must be MIPS-eligible) as identified by their NPI, who have reassigned their Medicare billing rights to a single TIN. If you report as a group, you must meet the definition of a group at all times during the performance period and aggregate the group’s performance data across the four MIPS performance categories for a single TIN. Each MIPS-eligible clinician in the group will receive the same payment adjustment based on the group’s performance across all four MIPS performance categories.(8)
Physicians also can report data as an individual and as part of a group under the same TIN. In this instance, the clinician will be evaluated across all four MIPS performance categories on his or her individual performance and also on the group’s performance, with a final score calculated for each evaluation. The clinician will receive a payment adjustment based on the higher of the two scores.(8)
Physicians also can report their MIPS data through a virtual group.(7) A virtual group is defined in the rule as “a combination of two or more [tax identification numbers] (TINs) assigned to one or more solo practitioners or one or more groups consisting of 10 or fewer eligible clinicians that elect to form a virtual group for a performance period for a year.”(7) To form and join a virtual group, physicians or clinicians must be eligible under MACRA, and at least one member of a group of 10 or fewer physicians or clinicians must not be exempt from having to comply with MACRA to be eligible to join a virtual group.(7) The benefits of joining a virtual group are that physicians and clinicians can band together to increase their MIPS scores by minimizing weakness in any one member and maximizing strengths.(7) The Advancing Care Information and Improvement Activities categories have not significantly changed from 2017.
In 2017, in order to avoid any adjustment in reimbursement—that is, to come out neutral—a total MIPS score of 3 points was required. This has been increased to an overall MIPS score of 15% to be eligible for a neutral adjustment in 2018. At the very least, a practice would have to report on the clinical practice improvement component in order to be able to get an overall score of 15 points. This is important for practices to know to avoid being penalized because even if they report enough accurate data they will need to add the clinical practice improvement component to avoid receiving a negative adjustment for the practice.
The exclusion criteria for 2018 have been adjusted as well, encompassing more physicians than previously.(7) The current exclusion criteria state that physicians are excluded if they either bill less than $90,000 to Medicare Part B or see 200 or fewer Medicare beneficiaries per year.(7) A physician who is new to Medicare is still excluded for that first calendar year. A formerly excluded physician who is a member of a practice group that decides to report MIPS data as a group may have to comply with MIPS if the group bills more than $90,000 to Medicare Part B or sees more than 200 Medicare beneficiaries.(7)
When it comes to reporting the data requested by MIPS, many physicians assume that they can simply rely on the electronic health record (EHR) they have grown accustomed to using in their daily practice. However, providers should ensure that they are informed on how to best maximize their existing EHR system for MIPS data collection, or to utilize a different system if necessary, so they are able to collect the necessary data to maximize positive adjustments and minimize negative adjustments per MIPS regulations. It is, therefore, recommended that physicians and practice groups find an outside professional who is fluent in the collecting and reporting of MIPS data to obtain the maximum compensation they are eligible for.(7)
A special point must be made regarding resident physicians in training and MIPS. Based on the exclusion criteria, most residents as individuals would not be eligible to participate until in practice one year out of residency training, because they would not meet the minimum Medicare billing and numbers requirements. However, to supplement their income, it is common for residents to choose to moonlight while in residency training. Some of these residents will apply for and obtain a Medicare provider number prior to graduation to be able to moonlight and use it for billing while moonlighting.(9) These residents would then start accumulating performance data that will be utilized for MIPS calculations.(8) Depending on where they moonlight, these residents could be at risk of receiving a poor performance score and a negative reimbursement adjustment in the future. Furthermore, practices looking to hire a new physician would be more reticent to hire someone with a low MIPS score—or, at the very least, it would negatively affect salary negotiation for such a resident. Therefore, residents should be informed of the risks and benefits of billing as a Medicare provider while moonlighting. Furthermore, it would be wise for residency programs to include MACRA and MIPS in their curricula so that residents who train there will not suffer unforeseen consequences and, more importantly, will be prepared to serve the many Medicare patients looking for a physician.
References
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Barbieri JS, Miller JJ, Nguyen HP, Forman HP, Bolognia JL, VanBeek MJ. Commentary: Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and CHIP Reauthorization Act of 2015. J Am Acad Dermatol. 2017;76:1203-1205.
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