MIPS, The Merit Based Incentives Payment System, has been in effect this year as a replacement for three former programs, though changes and rule updates are underway.  The government program was designed to be a way to focus on care quality and making patients healthier.  Not all of the healthcare stakeholders, including hospitals, physicians, and related groups, are happy with current MIPS Quality Payment Program rules, though some see the changes proposed for the next couple of years as positive.

MIPS Quality Payment Program

With MIPS, payments are based on a collection of quality measures such as resource use and clinical practice improvements, and the use of electronic health records (EHRs).  The Quality Payment Program combines the existing Medicare Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value-Based Modifier (VBM) programs into MIPS, starting with the 2017 performance year. MIPS payment adjustments are applied to Medicare Part B payments two years after the performance year. The payment adjustment year for the 2017 performance year will be 2019.

We asked Phil Williams, a MIPS specialist for Eagle Consulting Partners , how hard is it for the providers’ staff to use CPT codes for reporting? “The Quality Performance Category measures in MIPS are based off of billable services and diagnoses, using CPT/HCPCS and ICD-10 codes. ” explains Williams. “Many of Electronic Health Records (EHR) systems have this reporting capability built in and some will actually submit the data. However, often the EHR does not prioritize which measures will help clinicians earn the highest score. Understanding how your practice is using claim, modifier, and diagnosis codes can help you maximize reimbursement.

The SSI Group has a Claim Status module that helps our hospital clients review recurring Medicare claim errors and provides analysis and reporting. With SSI Claim Status, healthcare organizations can review automated claim status updates to proactively manage, and make real-time corrections in the Medicare Common Working File (CWF).

Not all concerned are happy with the current structure of MIPS. Fiercehealthcare.com writes that “the Medicare Payment Advisory Commission (MedPAC) made recommendations for changes to MIPS, one of two tracks under the Medicare Access and CHIP Reauthorization Act (MACRA), in its June report to Congress. The commission, which advises Congress on Medicare payment issues, devoted a chapter of its report to ways to improve MIPS by incorporating more patient outcomes and reducing the reporting burden on physicians. It also made recommendations to strengthen advanced alternative payment models.” MedPAC is a 15-member commission drawn from the medical field instituted to advise Congress on issues relating to Medicare.

The MedPAC commission submitted a long report (PDF is 315 pages) to Congress in June of this year, including a chapter addressing “redesigning the Merit-based Incentive Payment System and strengthening advanced alternative payment modules”.  Complexity is an identified issue in the chapter which notes, “because the measures can be reported in different ways, the result is over 600 reporting measures and method combinations for the 275 MIPS measures.”  In the conclusion of that chapter, the commission writes:

“MIPS as now designed will place a heavy burden on providers and CMS, but is unlikely to identify high-value clinician performance” — from MedPAC Report to The Congress, “Medicare and the Healthcare Delivery System.”

MIPS Quality Payment Program

Table of MIPS incentives from MedPAC Report to The Congress, “Medicare and the Healthcare Delivery System.”

An article in Health Affairs Blog, takes the criticism further, noting that more small physician practices have been excluded in current proposed rule changes. “In sum, delaying or denying MIPS participation for two-thirds of eligible clinicians is a step backward. The PQRS program, MIPS’s predecessor, did not have an exemption for clinicians with a low volume of Medicare patients or allowed charges. That CMS would propose to increase the exclusion thresholds is also puzzling because just seven months ago in the last year’s final MACRA rule, CMS stated, “we anticipate that more clinicians will be determined to be eligible to participate in the program in future years.”

In 2016, the American Hospital Association (AHA) put out a brief (PDF) on Physician Payment Reform, that in part recommended: “a quality and resource use measure reporting option in which hospital-based physicians can use CMS hospital AHA Position quality program measure performance in the MIPS.”  The AHA is behind some of the recently proposed changes for the MIPS Quality Payment Program.  In a press release from June of 2017, Tom Nichols, AHA Executive Vice President said, “Today’s proposed rule continues the incremental, flexible implementation approach called for by hospitals, health systems and the more than 500,000 employed and contracted physicians with whom they partner to deliver care. We are encouraged by CMS’s proposal for a facility-based clinician reporting option that may promote better alignment and collaboration on efforts to improve quality among hospitals and clinicians.”

While a micro focus on MIPS scoring and reporting helps maximize incentives, in the big picture, MIPS results could have a wider impact on physicians’ and providers’ futures.  Rita E. Numerof, president of Numerof & Associates, writing for FierceHealthcare notes, “MIPS reporting could have impact beyond physician compensation under Medicare Part B. If the data points influence patients’ choice of physicians (directly, or via insurers or employers that steer them to the highest performing doctors), the scores may also influence a provider’s referral stream, reputation, and overall market share.”