How ECPs can Win at MIPS: Performance Categories, Scoring, and More

Ready or not, here it comes!

While the door is still open for a delay, the Quality Payment Program (QPP) is slated to begin January 1, 2017. That means you’ll only have two months till go-live if the final rule is issued in November, as anticipated.

CMS has indicated all along that it is open to “multiple approaches” including delayed or alternative start dates.

Acting Administrator Andy Slavitt had previously agreed that a delayed start would particularly benefit solo, small, and rural practices.

It’s anyone’s guess as to what will happen come January 1, but as an Eye Care Leader, you’ll know what to expect. Below, a quick rundown on how most ECPs will participate, the four performance categories, and how MIPS scoring works:

For the first performance year, 2017, all participants start out on the MIPS track. After that, participants have the option to take the APM track, which offers exemption from MIPS. However, ECPs will likely remain on the MIPS track for the foreseeable future.

Here’s where it gets tricky: If you participate in an APM but don’t meet the QP requirements, you can still participate in MIPS. Remember, the APM track only rewards advanced APMs—those models that include both upside and downside risk. Only 4-11 percent of ECs are expected to qualify as advanced APMs according to the Brookings study. So say you’re part of an ACO—like Medicare Shared Savings Program Track 1— or PCMH. Participation in those APMs may not qualify you to take the APM track, but it will give you favorable scoring in the MIPS CPIA category—anywhere from 50 to 100 percent credit.

You’ll participate in MIPS as either an individual or group. It’s your choice, but if your practice goes for the group option, you’ll report as a group for all four categories. You can’t mix and match by reporting individually for some categories and as a group for others.

MIPS weighs your performance in four categories. It combines the three current independent programs of Meaningful Use, PQRS, and the Value-based Modifier (VBM), and adds a new, 4th category.

1. Quality Performance (fka PQRS)

This category takes the nine measures you now report for PQRS and reduces that requirement to six. But there’s an emphasis on outcomes, and this could spell trouble for ECPs. ECPs treat patients with chronic conditions where full recovery isn’t an option. Managing diseases like glaucoma and AMD depends on patients’ consistent use of prescribed drops and frequent in-office appointments for pressure checks. Should physicians be held responsible for unrealistic outcomes or outcomes dependent on patient compliance? Organizations like ASCRS say ‘no.’

2. Resource Use (fka VBM)

For this category, you don’t actually have to “report” anything; CMS calculates your score based on your submitted claims. Based on the existing VBM methodology, it proposes to keep two of the six current VBM measures and adds over 40 new episode-specific measures.

ASCRS commentary notes troubling holdovers from the VMB program: (1) the methodology potentially holds specialists responsible for care they did not provide, and (2) the cost measures are primary care-focused and do not apply to specialists, particularly ophthalmologists.

3. Advancing Care Information (fka MU)

This category emphasizes interoperability, information sharing, and security, and contains the previously-mentioned “all-or-nothing” component that the QPP largely eliminates. Scoring starts with a 50-point base score, then adds an additional performance score, plus a bonus score. To earn points for the performance and bonus scores, you must earn the 50 points for the base score. That base score is all-or-nothing, based on six measures carried over from MU.

Unlike MU, the EHR measurement is no longer pass/fail. ECs simply report a numerator/denominator score to earn varying levels of credit. Additionally, ECs can emphasize their scoring in categories of their choice for their performance score.

4. Clinical Practice Improvement Activities (new category)

If you participate in an APM, you’re already partially covered here.  If you don’t, you’ll have to choose at least one activity to avoid a zero in this category. There are more than 90 proposed activities to choose from in—the more activities you do, the higher your score. Choosing a “high-value” activity will net you extra points.

MIPS Scoring Made Simple(r)

MIPS seeks to tie fee-for-service payment to quality and value. Over time, the way the Quality and Resource Use categories are weighted will change to reflect an increased emphasis on cost. The weights of the CPIA and ACO categories will not change:

Quality

2017: 50%, 2018: 45%, 2019: 30%

Resource Use

2017: 10%, 2018: 15%, 2019: 30%

CPIA

2017: 15%, 2018: 15%, 2019: 15%

ACI

2017: 25%, 2018: 25%, 2019: 25%

MIPS is “graded on a curve.” Your composite score will be compared to a performance threshold created from the composite scores of all ECs. Here’s how the risks and rewards stack up:

  • ECs  with scores between 0-25 percent of the threshold get maximum negative penalty.
  • As you approach the threshold, the penalties get smaller.
  • ECs at the threshold receive no adjustment.
  • ECs above the threshold receive proportionally larger incentive payments.
  • Exceptional performers (those in the top 25 percent) receive an additional incentive payment.

Photo Credit: jayneandd CC BY 2.0

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