Merit-based Incentive Payment System (MIPS)

MACRA Basics

Merit-based Incentive Payment System (MIPS)

2018 MIPS Playbook

Get the step-by-step guide to MIPS under MACRA's QPP.

Free for Members

More on the MIPS Performance Categories

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

MIPS: One of Two Payment Tracks Under the Quality Payment Program (QPP)

The Medicare Access and CHIP Reauthorization Act (MACRA) permanently repealed the flawed sustainable growth rate (SGR) and set up the two-track Quality Payment Program (QPP) that emphasizes value-based payment models.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.

Quality Payment Program (QPP) Changes for 2018

On November 2, 2017, the Centers for Medicare & Medicaid Services (CMS) released updates to the QPP for the 2018 performance period. Major program changes include:

  • Addition of a small practice bonus – Eligible clinicians (ECs) in small practices (15 or fewer clinicians) will receive a five-point bonus added to their MIPS final score.
  • Addition of a complex patient bonus – ECs can receive up to five bonus points to their final score for providing care to complex patients. The size of this bonus is based upon average hierarchical condition category (HCC) risk scores and proportion of dual-eligible patients.
  • Increased low-volume threshold – ECs who provide care to less than or equal to 200 Medicare Part B beneficiaries or received less than or equal to $90,000 in Medicare Part B payments are excluded from MIPS. ECs can check their MIPS-eligibility status on the QPP website(qpp.cms.gov).
  • Longer performance period – The performance period for the quality and cost categories is a full calendar year (January 1 - December 31, 2018). The performance period for the improvement activities and advancing care information (ACI) categories is any consecutive 90 days.
  • Increased data completeness – In the quality category, ECs must report on at least 60% of patients eligible for the measure, regardless of payer.
  • Increased cost weight/decreased quality weight – The weight of the cost category has increased to 10% for the 2018 performance period. The weight of the quality category has decreased to 50%. The quality and cost performance categories are scheduled to be equally weighted at 30% starting with the 2019 performance period.
  • Virtual groups available – Solo and small practices (10 or fewer clinicians) can join together to participate in MIPS as a virtual group.
  • Small practices can apply for a hardship exemption in the ACI category.
  • To accommodate ECs affected by extreme and uncontrollable circumstances, such as natural disasters, CMS has made hardship exemptions available for the quality, cost, and improvement activities categories. This is in addition to the pre-existing ACI hardship exemptions.

Access the Family Practice Management (FPM) article, “Making Sense of MACRA in 2018: Six Things to Know” for additional information on the updates to the 2018 performance period.

Merit-based Incentive Payment System (MIPS) Overview

The Merit-based Incentive Payment System (MIPS) is one of the two payment tracks created under MACRA; the other is the Advanced Alternative Payment Model (AAPM) track. MIPS adjusts payment based on performance in four performance categories:

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

Performance Periods
Performance Periods: Performance Category201820192020
Performance Periods: Quality50%30%30%
Performance Periods: Cost10%30%30%
Performance Periods: Advancing Care Information25%*25%*25%*
Performance Periods: Improvement Activities15%15%15%

*If the Secretary of the U.S. Department of Health and Human Services (HHS) determines the proportion of eligible clinicians who are “meaningful users of electronic health records (EHRs)” is estimated at 75% or greater, the weight of the ACI category may be reduced. The remaining performance categories will be increased by the corresponding number of percentage points. The lowest weight the ACI category can carry is 15%.

Performance in each category is weighted and used to calculate a final score (0-100). Each EC or group’s final score is compared to a performance threshold to determine payment adjustments. The performance threshold for the 2018 performance period is 15 points.

  • Final scores above the threshold will receive a positive payment adjustment.
  • Final scores below the threshold will receive a negative payment adjustment.
  • ECs in the lowest quartile will receive the maximum payment adjustment for a performance period.
  • Final scores equal to the threshold will receive a neutral payment adjustment.

Payment adjustments are budget neutral and made on a sliding scale. To maintain budget neutrality, physicians with higher final scores may be eligible for a positive payment adjustment up to three times the baseline positive payment adjustment for a given year.

Payment adjustments, based on the final score, are based on performance from two years prior (e.g., performance in 2018 determines payment adjustments in 2020). Adjustments are made on the following sliding scale:

Performance Year

Payment Year

Potential Positive/Negative Payment Adjustment

Performance Year

:

2018

Payment Year

:

2020

Potential Positive/Negative Payment Adjustment:

±5%

Performance Year

:

2019

Payment Year

:

2021

Potential Positive/Negative Payment Adjustment:

±7%

Performance Year

:

2020

Payment Year

:

2022

Potential Positive/Negative Payment Adjustment:

±9%

Performance Year

:

2021

Payment Year

:

2023

Potential Positive/Negative Payment Adjustment:

±9%

 

Exceptional performers that meet the additional performance threshold could receive an additional sliding scale positive payment adjustment of up to 10%. The exceptional performance threshold for the 2018 performance period has been set at 70. Exceptional performance adjustments occur outside of budget neutrality.

Physicians can participate as either individuals or groups. When reporting as a group, all ECs reporting within the tax identification number (TIN) must be included in the group’s reporting. The MIPS final score will be applied to each national provider identifier (NPI) within the TIN. Additionally, a TIN cannot be split into multiple groups.

Eligible clinicians excluded from MIPS include:

  • Eligible clinicians who provide care to less than or equal to 200 Medicare Part B patients, OR have less than or equal to $90,000 in Medicare Part B allowed charges.
  • Eligible clinicians in their first year of participation in Medicare.
  • Qualifying and partial qualifying Advanced Alternative Payment Model (AAPM) participants who qualify for the AAPM bonus. Partial QPs may elect to report to MIPS.

MIPS-eligible clinicians will receive a 0.25% increase in their physician fee schedule (PFS) beginning in 2026. Those in AAPMs will receive a 0.75% physician fee schedule (PFS) update beginning in 2026.

MIPS Performance Categories

Note: percentage weights and criteria based on the 2018 performance period.

Quality – 50%

  • Physicians report six 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 readmission measure for groups of 16 or more eligible clinicians who have at least 200 eligible cases.
  • Physicians must report on 60% of patients that qualify for each measure selected, regardless of payer, unless reporting via claims or the CMS Web Interface, where only Medicare Part B patients are included.

The AAFP’s MIPS Measures Reference Guide can help you review and select quality measures to report.

Cost  – 10%

  • No data submission is required.
  • CMS calculates cost using claims data.
  • Measures include Medicare Spending per Beneficiary (MSPB) and Total per Capita Cost.
  • CMS is currently developing new episode-based cost measures for use in future program years.

Advancing Care Information (ACI) 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.
  • In the 2018 performance period, ECs who only utilize 2015 edition certified electronic health record technology (CEHRT) qualify for a 10-point ACI bonus.
  • Physicians can report additional measures to receive a higher performance score.
  • The performance score is based on the actual performance rate for each measure reported (excludes security risk analysis and e-prescribing).

MIPS Reporting Options

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


What You Need to Know About QPP and MIPS

Watch this short video to hear family physicians John Meigs, Jr., MD, FAAFP, and Amy Mullins, MD, CPE, FAAFP, to learn more about:

  • What MIPS and QPP are
  • What the four MIPS performance categories are, and who is excluded
  • What the Quality category in MIPS is
  • How the Cost category is scored in 2017
  • What the MIPS final score is