First, consider the continuum of VBR programs. Given how volume-based and value-based programs incentivize very different behaviors – the former rewards providing more services regardless of outcomes while the latter rewards better outcomes regardless of the number of services provided – the transition from volume to value cannot happen overnight. Instead, there will be a transition period during which payers will learn to measure and reward value and providers will learn how to demonstrate value.
The following chart shows the path from today’s fee-for-service payments to tomorrow’s population-based alternative payment models (APM). Along the way, payers will reward providers based on identified performance measures, based on the assumption those who do well on these measures are better positioned to effectively manage population health. These interim VBR programs also reward provider networks working together to lower patients’ total cost of care.
Source: Pershing, Yoakley & Associates
The new MIPS program falls under part C of the Adjusted FFS Payments, as it varies the amount a physician receives in payment under the Medicare Physician Fee Schedule (MPFS) based on their composite performance score, or CPS. Assume, for example, the MPFS rate for a certain service is $100. In the first year of MIPS payment adjustments, a physician scoring above the national median may receive up to $104 for that service, while a physician scoring below the national median may receive as little as $96. Physicians scoring at the very top will receive extraordinary performance payments, up to 10 percent of their Medicare allowed charges.
For the 2017 performance year – which is now scheduled to start January 1, 2017 – a physician’s CPS will be weighted as follows:
- 50 percent quality
- 10 percent resource use
- 25 percent advancing care information (meaningful use)
- 15 percent clinical practice improvement activities
A physician or group will report on 2017 performance in the first quarter of 2018, and CMS will publish individual physicians’ CPSs later that year. Individual payment adjustments based on these CPSs will commence January 1, 2019.
While each physician will be assigned an individual CPS, scores on performance measures may be reported individually or as a group. In the case of group reporting, all physicians who are part of the group will receive the same score based on the group’s performance. A physician who is part of a practice that reports as a group may also report individually. In that case, CMS will assign the higher score to that physician.
Thus, the group score serves as a base score, with poorer-performing physicians benefitting from the work of their higher-performing colleagues. At the same time, higher-performing physicians can avoid the negative impact of their poorer-performing colleagues by also submitting their individual scores. An individual physician also may elect to report on different measures than the group, given differences in his or her practice as compared to the group.
Because one-half of a physician’s CPS will be tied to performance on quality measures, these measures demand greater attention in the near term. Let’s start with some good news: the MIPS quality performance reporting requirements are less onerous than the current PQRS requirements. An individual physician or group must report on at least six quality measures as compared to the nine measures now required for PQRS reporting. Also, PQRS requires the selection of measures from at least three of the six National Quality Strategy domains; there is no similar requirement for MIPS.
The individual or group will select measures from the annual master measures list published by CMS by November 1 of the year preceding the performance year. In the May 9 MIPS proposed rule, CMS included a preliminary list of 300+ quality measures, which overlap significantly with the 2016 PQRS approved measures.
Of the six MIPS quality measures on which an individual or group reports, one must be from the 10 identified “cross-cutting measures,” which are non-specialty specific measures focused on overall population health:
- Advance Care Plan
- Documentation of Current Medications
- Tobacco Screening and Cessation Intervention
- Controlling High Blood Pressure
- Screening for High Blood Pressure
- Receipt of Specialist Report
- Adolescent Tobacco Use
- Screening for Unhealthy Alcohol Use
- BMI Screening and Follow-up Plan
- CAHPS Patient Satisfaction Survey
Another one of the six reported measures must be categorized as an outcome measure (vs. the more common process of care measures). CMS’ MIPS master measures list identifies those measures qualifying as outcome measures. Other measures are identified as “high priority” measures for which a physician may receive bonus points.
Although CMS only requires reporting on six measures, a physician or a group may elect to report on additional measures. CMS will select the best six scores to calculate the quality component. Thus, reporting on additional measures may give a provider a better opportunity to earn a higher overall score.
In addition to reported measures, CMS also proposes to include up to three population-based measures derived from claims data in calculating MIPS quality scores. These measures now are used in the Physician Value-Based Modifier Program:
- Risk-adjusted rate at which attributed Medicare beneficiaries are hospitalized with a primary diagnosis of bacterial pneumonia, urinary tract infection, or dehydration
- Risk-adjusted rate at which attributed Medicare beneficiaries are hospitalized due to complications arising from diabetes, heart failure, or COPD/asthma
- Risk-adjusted rate of 30-day all-cause hospital readmissions.
For each measure on the MIPS master measures list and for the population-based measures, CMS will establish a separate benchmark based on national performance during a baseline period. For those measures for which there is no historical data (e.g., new measures), CMS will use performance year data to establish the benchmarks.
CMS will break baseline-period performance into deciles. Then, CMS will compare a physician’s or group’s actual performance to those deciles to determine the number of points to be assigned to the Clinician or group for that measure. CMS offers the following example of point assignment based on decile scoring: