Merit-based Incentive Payment System (MIPS)

MACRA Basics

Merit-based Incentive Payment System (MIPS)

More on the MIPS Performance Categories

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The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) permanently repealed the flawed sustainable growth rate (SGR) and set up a new two-track Medicare physician payment system that emphasizes value-based payment models. The Merit-based Incentive Payment System (MIPS) track replaces three existing quality programs and adds a new performance category.

MIPS Overview

MIPS is one of the two new payment tracks created under MACRA; the other track is the Advanced Alternative Payment Model (AAPM).

MIPS adjusts payment based on performance in four performance categories:

  • Quality – based on the Physician Quality Reporting System (PQRS)
  • Cost – based on the Value-based Payment Modifier (VBPM)
  • Advancing Care Information (ACI) – based on the Medicare EHR Incentive Program (Meaningful Use)
  • Improvement Activities (IA) – a new category

Performance categories carry different weights that will shift as the program progresses.

Performance Category

2017

2018

2019

Performance Category

:

Quality

2017

:

60%

2018

:

50%

2019

:

30%

Performance Category

:

Cost

2017

:

0%

2018

:

10%

2019

:

30%

Performance Category

:

Advancing Care Information

2017

:

25%

2018

:

25%

2019

:

25%

Performance Category

:

Improvement Activities

2017

:

15%

2018

:

15%

2019

:

15%

Performance in each category is weighted and used to calculate a final score (0-100).

Payment adjustments, based on the final score, are budget neutral and based on performance from two years prior (e.g., performance in 2017 determines payment adjustments in 2019). Adjustments are made on the following sliding scale:

Performance Year

Payment Year

Positive/Negative Payment Adjustment

Performance Year

:

2017

Payment Year

:

2019

Positive/Negative Payment Adjustment:

±4%

Performance Year

:

2018

Payment Year

:

2020

Positive/Negative Payment Adjustment:

±5%

Performance Year

:

2019

Payment Year

:

2021

Positive/Negative Payment Adjustment:

±7%

Performance Year

:

2020

Payment Year

:

2022

Positive/Negative Payment Adjustment:

±9%

Performance Year

:

2021

Payment Year

:

2023

Positive/Negative Payment Adjustment:

±9%

Additional positive adjustments are possible due to budget neutrality.

Exceptional performers that meet the additional performance threshold could receive an additional sliding scale positive payment adjustment of up to 10%. Exceptional performance adjustments occur outside of budget neutrality.

Physicians can participate as either individuals or groups.

Eligible clinicians excluded from MIPS include:

MIPS-eligible clinicians will receive a 0.25% increase in their physician fee schedule (PFS) beginning in 2026.

Eligible clinicians can avoid the 2019 negative payment adjustment by using one of the Pick Your Pace options.

MIPS Performance Categories

Note: percentage weights and criteria based on performance year 2017

Quality – 60%

  • Physicians report 6 measures, one of which must be an outcome measure.
  • The Centers for Medicare & Medicaid (CMS) will use claims data to calculate the all-cause hospital readmissions measure for groups of 16 or more eligible clinicians who have at least 200 eligible cases.
  • All measures available under PQRS are available in MIPS.
  • To receive the highest score possible, physicians must report on 50% of patients that qualify for each measure chosen, regardless of payer, unless reporting via claims or the CMS Web Interface where only Medicare Part B patients are included.

Get the list of quality measures from CMS »(qpp.cms.gov)

Cost – 0%

  • No data submission is required.
  • CMS calculates cost using claims data.
  • Measures include Medicare spending per beneficiary (MSPB), total per capita costs, and condition and episode-based measures (predominately based on inpatient codes).

Advancing Care Information – 25%

  • ACI is comprised of the base score (50%) and performance score (50%).
  • The base score requires a numerator/denominator or yes/no statement for each required measure.
  • Physicians must report all required measures to receive a base score. Failure to achieve a base score will result in a score of zero for the entire performance category.
  • Required measures vary depending on which version of certified EHR technology (CEHRT) utilized (2014 edition CEHRT or 2015 edition CEHRT).
  • Physicians can report additional measures to receive a higher performance score.
  • The performance score is based on actual performance rate for each measure reported (excludes security risk analysis and e-prescribing).

Get the list of ACI measures from CMS »(qpp.cms.gov)

Improvement Activities – 15%

  • Select from a list of 92 activities(qpp.cms.gov)
  • Physicians will report two high-weighted activities (worth 20 points each) or four medium-weighted activities (worth 10 points each), or a combination to achieve 40 points total.
  • Eligible clinicians in small practices (15 or fewer clinicians), rural practices, or health professional shortage areas (HPSA) can report one high-weighted activity or two medium-weighted activities (measures are double weighted).
  • Certified patient-centered medical homes (PCMH) will automatically receive full credit.

Get the list of improvement activities from CMS »(qpp.cms.gov)

MIPS Reporting Options

You may report using different mechanisms between categories, but only one method of reporting can be used within each category.

  • Medicare Part B claims-based reporting
  • Qualified Registry
  • Certified electronic health record technology (CEHRT)
  • Qualified clinical data registry (QCDR)
  • CMS Web Interface (for groups of 25 or more eligible clinicians)

More on the MIPS Performance Categories

Want to dig deeper into the performance categories associated with MIPS?