Replacing the Physician Quality Reporting System (PQRS) in 2017, the Merit-Based Incentive Payment Program (MIPs) aims to incentivize providers for delivering high-value care to patients. Providers who meet the program’s low volume requirements must participate or else be subject up to a -9% penalty imposed on future Medicare part B claims. Each year, the MIPS program increased in difficulty and is now at the point where the risk of a penalty is very real for many participants for 2022 and beyond.
Why is it so hard to avoid a penalty?
Penalty Bar Set High – 75 points
As of 2022, The Quality Payment Program (QPP) governing the MIPs program is required to use actual participate data when setting the year’s performance threshold rather than establishing these thresholds themselves. The QPP used participant data from the 2017 performance year, where overall performance was very high, to establish the 2022 penalty threshold of 75 points.
Topped Out/Point Capped Quality Measures
The MIPs program expects participants to report at least 6 measures in the Quality category. Each year the QPP makes updates to the available inventory of measures to add, change, or remove them and establish scoring benchmarks for the next performance year.
When the QPP identifies measures with very high-performance rates across all participants, steps are taken to disincentivize providers from continuing to report on that particular measure.
The first step in that initiative is where the QPP will designate the measure as being ‘topped out’ when median performance is 95% or higher. When this happens, the measure will require a performance rate of 100% to return the maximum number of points (10 points) towards the category score. Any performance below 100% will lower the number of points returned significantly – in extreme cases this can mean a difference of 7 points, lowering a score return from 10 to 3 points.
After a measure is designated as ‘topped out’ for consecutive performance years, the QPP can then apply a ‘point cap’ and reduce the maximum amount of points awarded for a measure. When this happens, the measure’s maximum point value will be lowered from 10 points to 7 points. The measure remains ‘topped out’ requiring 100% performance to earn the maximum points.
After several years of annual updates, many specialties now have few options for nationally available measures that aren’t already topped-out and point-capped.
Participants may be able to utilize a QCDR (Qualified Clinical Data Registry) to report on alternative Quality measures approved for the MIPS program as alternatives to topped-out/point-capped measures but this does not guarantee a higher Quality score. QCDR measures are only available to report by the specific QCDR that created the measure unless it’s been licensed to another QCDR. This means that participants will need to be cognizant of what measures are available and with who. Additionally, many QCDR measures do not have benchmarks at all since QCDR measures are not as widely utilized as nationally available measures. Before joining a QCDR, participants should review possible measures to see if a historical benchmark is available as measures without benchmarks will not contribute to the Quality score.
Bonus Points Diminishing
Since its beginning, the MIPs program has featured bonus points across several categories as well as towards the final overall score. Ultimately, the MIPs program envisions a future without bonus points at all and took steps to remove bonuses awarded for end-to-end electronic reporting and high-priority measure reporting starting with the 2022 performance period. Up until this year, participants were granted an extra 1 bonus point for reporting extra high-priority type measures towards the Quality category as well as 2 bonus points if reporting a measure via an EHR. These bonus points could add up to a maximum of 6 points towards the Quality category score. These extra points were extremely useful in terms of avoiding penalties or achieving higher bonuses, particularly in cases of reporting point-caped measures. With these bonus points gone, many practices are left with no way to make up those points and are now facing a risk of a penalty. On the positive side, the Small Practice bonus of 6 points towards the Quality category has been maintained and is still available for those in groups of 15 or fewer.
Although not removed from the program entirely, the MIPS program altered the attribution methodology for the Complex Patient Bonus beginning in 2022. This bonus was generally applicable to all participants and applied towards the final score, typically resulting in an extra 1 – 5 points added to the overall score. The change is that, now this bonus will only apply to providers caring for medically complex or dually eligible (Medicare and Medicaid) patients, meaning this bonus will no longer be generally applied across the board.
What can you do about it?
Control What Can Be Controlled
With the exception of the Cost category, which is calculated by CMS, MIPs participants can manage the remainder of their score by ensuring category specific goals are met. For most specialties, the Quality category ends up being the biggest driver of the final score.
To that end, we suggest that participants should make the Quality category a particular focus and review performance on any quality measures below 100% performance.
Identifying trends in the data failing to meet performance requirements can pin down possible root causes. For example, consistencies in procedure type or provider for reports ‘missing’ a measure could indicate an opportunity to update a template or workflow.
Provider education may be needed if you find encounters failing a measure for similar reasons, particularly if there have been changes to a measure from one year to the next. Measure requirements (documentation, applicable procedures) should be reviewed ahead of each performance year to account for any changes made through rulemaking.
For those who submit Quality data with a vendor, such as a Qualified Registry, we suggest you consider managing measure performance with corrections throughout the year. This is one of the major advantages of being part of a Qualified Registry – the ability to make corrections before the year is finalized. So, depending on which measure is being reported, you may have the opportunity to add deficient information prior to submitting data at the end of the year to reach the goal of 100% performance.
We believe that managing measure performance is crucial to success given the high penalty bar.
Those who might be anxious about MIPs performance could explore becoming exempt from MIPs by participating in the other track of the Quality Payment Program (QPP) – Advanced APMs. Advanced APMS (Alternative Payment Models) are entities that seek to deliver value-based care with alternatives to fee-for-service reimbursement, such as bundled payments or shared savings. The QPP considers an APM ‘advanced’ when it incorporates Quality reporting and participants assume financial risk. When a provider otherwise eligible for MIPs joins an Advanced APM, they will become exempt from MIPs reporting once a certain threshold of patients or payments go through the APM.
There should be several other factors taken into consideration prior to joining an Advanced APM as there would be larger reimbursement implications outside of just becoming MIPS exempt. If exploring joining an APM, make sure to have a solid understanding of the payment structure (bundled-payments, episode-based payments, risk-adjusted reimbursement etc), quality reporting requirements, and downside financial risk to determine if it’s right for the practice.
One potential short-term solution, available in 2022, could be applying for the program’s Extreme and Uncontrollable Circumstances (EUC) policy to request category reweighting for the performance year – meaning that Participants encountering situations impacting the collection or submission of data can request that any, or all, performance categories be weighted to 0% resulting in a neutral payment adjustment for the payment year if accepted (i.e. no penalty, no incentive). Although not generally available each year, MIPs has offered these EUC hardship applications, specifically due to COVID-19, since the 2020 performance year and are once again offering it for 2022.
It is not expected that this EUC hardship for COVID will be available again in 2023, but this may change depending on the duration of the public health emergency.
We believe that, even if a penalty cannot be avoided, it is still worth trying to score as high a score as possible to mitigate how much of a penalty is applied to future claims.
The closer a final score is to the penalty threshold of 75 points, positive or negative, the smaller the payment adjustment will be. The maximum allowable adjustment (-9%) is only applied to the bottom-most scores. For 2022, those that earn at least 20 points overall will avoid the full -9%. Scores closest to the penalty threshold (75) may only see an adjustment of -1%.
The proposed updates for the MIPs program for 2023 will not change the current performance goals active in the 2022 performance year – meaning practices will continue to need scores of 75 points or higher to avoid a penalty.
Reviewing your current MIPS performance is recommended to evaluate areas of risk for 2022 and 2023.
As always, ADVOCATE will keep you up to date on this and all issues impacting medical groups as they become available.
Manager, Regulatory Affairs