MIPS Payment Track:

Cost Performance Category

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MIPS: Explaining the Cost Performance Category

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 the two payment tracks:

MIPS and AAPMs are collectively referred to as the Quality Payment Program (QPP).

With the MIPS track, ECs receive a final score based on performance in four performance categories: quality, cost, promoting interoperability (PI), and improvement activities.

Cost Reporting

The cost category will be weighted at 10% of a clinician’s final score under MIPS for the 2018 performance period, and 30% for the 2019 performance period and beyond.

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.

Beginning in 2018, clinicians will be assessed on their performance in:

  • Medicare Spending per Beneficiary (MSPB)
  • Total per Capita Cost

The MSPB and Total per Capita Cost measures were included in the Value-based Payment Modifier calculation. 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:

  • Clinicians who do not see patients in the hospital will not be attributed to any episodes and not scored on the measure.
  • Clinicians must be attributed to at least 35 cases to be scored on this measure.
  • Episodes will be attributed to the clinician who provided the plurality of Medicare Part B services to a beneficiary during an index admission.

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:

  • Clinicians must be attributed to at least 20 unique beneficiaries to be scored on this measure.
  • Attribution uses the following two-step process:
    1. A beneficiary is attributed to a tax identification number-national provider identifier (TIN-NPI) if the beneficiary received more primary care services from primary care physicians, nurse practitioners, physician assistants, or clinical nurse specialists within that TIN than from clinicians in any other TIN.
    2. If a beneficiary cannot be attributed to a TIN-NPI using the first step, the beneficiary will be attributed to a TIN-NPI if they received more primary care services from specialist physicians within a TIN than from clinicians in any other TIN.
  • CMS is developing new episode-based cost measures. The first round of episode-based cost measures will be introduced in the 2019 performance period.

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.

  • A measure will be benchmarked if it has 20 groups or individual clinicians who can be attributed to the case minimum for the measure.
  • A measure without a benchmark will not be scored or included in the performance category score.

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.

  • For example, a TIN may have one clinician with 10 attributed cases and another with 12 attributed cases. If they are reporting as individuals, they would not be scored on the measure. However, if they were reporting as a group, they would receive a score since they reach the 20-case minimum threshold (10 cases + 12 cases = 22 cases).

Beginning with the 2018 performance period, CMS will incorporate improvement in to the cost category score.

Improvement is measured at the measure level. ECs can earn a maximum of one improvement point.

The Centers for Medicare & Medicaid Services will calculate improvement by subtracting the number of measures with significant decline in performance from the number of measures with significant improvement in performance. The difference is then divided by the number of measures for which the EC was scored in both performance categories.

Measures available for improvement scoring in 2018 include Total per Capita Cost and MSPB.

While cost was not scored in 2017, CMS will use performance on these measures to calculate improvement.

If an individual or group does not receive a cost score, the weight for the cost category will be redistributed to the quality category.