Under the Medicare Access and CHIP Reauthorization Act (MACRA), which was passed and signed into law in April 2015, eligible clinicians (ECs) will participate in either of the two payment tracks:
MIPS and AAPMs are collectively referred to as the Quality Payment Program (QPP).
The cost category is weighted at 15% of a clinician’s final score under MIPS for the 2019 performance period. Currently, the weight of the cost category will gradually increase until it reaches 30% in the 2022 performance year.
There is no data submission required for the cost category. The Centers for Medicare & Medicaid Services (CMS) will calculate cost measures of a clinician’s performance using claims data.
Clinicians are assessed on their performance on:
The MSPB measure assesses Medicare Part A and B costs incurred during an episode. An episode includes the dates falling between three days prior to an Inpatient Prospective Payment System (IPPS) hospital admission (referred to as an index admission) and 30 days post-hospital discharge. The MSPB measure evaluates the observed cost of episodes compared to their expected costs. For the MSPB measure:
The Total per Capita Cost measure assesses all Medicare Part A and B costs for each attributed beneficiary. For the Total per Capita Cost measure:
Many of the new episode-based cost measures will not apply to family physicians. CMS is developing additional episode-based measures for future program years. The episode-based cost measures for the 2019 performance year include:
Cost measures are risk-adjusted to account for differences in patient characteristics, such as multiple chronic conditions that may affect a clinician’s performance on the measure. Risk adjustment will be based on hierarchal condition category (HCC) risk scores.
Cost measure benchmarks are established using data from the performance period.
An EC’s performance will be compared to the measure benchmark and assigned 1 to 10 points.
The cost performance category score is the average of all scored cost measures.
When reporting as a group, CMS will aggregate the scores of individual clinicians within the TIN.
If an individual or group does not receive a cost score, the weight for the cost category will be redistributed to the quality category.
Measure specifications for the cost measures can be found in the QPP Resource Library.