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Quality Payment Program
The Centers for Medicare & Medicaid Services (CMS) launched the Quality Payment Program (QPP) in 2017, the goal of which was to reward improved patient outcomes and drive fundamental movement toward a value-based system of care.
The program offers 2 payment tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).
The MIPS track streamlined three legacy CMS programs:
- Physician Quality Reporting System (PQRS)
- Value-Based Payment Modifier
- Medicare Electronic Health Record (EHR) Incentive (or Meaningful Use) Program
Clinicians are evaluated and receive payment adjustments based on their overall performance in up to four performance categories:
- Quality
- Cost
- Improvement Activities (IA)
- Promoting Interoperability (PI)
Clinicians who were eligible for MIPS in the 2021 performance year will receive a payment adjustment during the 2023 payment year — positive, neutral, or negative — based on their performance in 2021. The MIPS track pertains only to providers of professional services paid under Medicare Part B.
The Advanced APM track provides an opportunity to reward clinicians for significant participation in taking on greater risk and accountability for patient outcomes. Eligible clinicians who participated in an Advanced APM and achieved Qualifying APM Participant (QP) status, based on the level of their participation in 2021 through the Medicare or the All-Payer Combination Option, will be eligible to receive a 5% APM Incentive Payment in 2023.
Eligible clinicians with QP status are also excluded from MIPS. If an eligible clinician participating in an Advanced APM doesn’t achieve QP status for the year, they’ll need to participate in MIPS, unless they’re otherwise excluded.
MIPS tracks data in four performance categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. Each category is weighted and contributes to a MIPS eligible clinician’s or group’s final score.
MIPS Year 7 (2023) performance categories and weights in the final score are??
The Cost category assesses eligible clinicians and groups on the resources used to treat attributed Medicare beneficiaries. For the 2023 performance year, Cost performance accounts for 30 percent of a MIPS final score. Unlike other MIPS categories that require data submission, cost performance is measured via Medicare Part B claims data.
MIPS participants are awarded points based on their cost performance against measure benchmarks. In 2023, the Cost performance category measures include:
- Total per Capita Cost measure
- Medicare Spending per Beneficiary Clinician (MSPB-C) measure
- Episode-based measures
Quality is worth 30 percent of an eligible clinician’s or group’s MIPS final score in the 2023 performance year. MIPS participants can choose from hundreds of quality measures and must submit a full year of data on six quality measures for compliance in this category. Each measure is worth up to 10 points, with the number of points earned based on data completeness compared to national benchmarks.
Achieving the highest score in the Quality performance category (60 points) requires MIPS eligible clinicians to report at least one outcome measure or high-priority measure. A high-priority measure is a MIPS quality measure listed in the categories for outcome, appropriate use, patient safety, efficiency, patient experience, care coordination, or opioid-related measures.
For the 2023 performance period, CMS moves away from using historical benchmarks for scoring administrative claims measures and will use performance period data. New measures will have a 7-point scoring floor for the first performance period and a 5-point scoring floor in the second performance period.
The MIPS Improvement Activities category identifies measures for improving clinical practice or care delivery that potentially result in improved patient outcomes. Improvement activities focus on care coordination, patient engagement, and patient safety.
The Improvement Activities category is worth 15 percent of the MIPS final score. To earn full credit, a clinician or group must complete activities equal to a maximum 50 points or successfully participate in a patient-centered medical home or medical home payment model, or in a similar specialty practice and a MIPS APM.
Promoting Interoperability, formerly called Advancing Care Information (ACI), requires the meaningful use of certified electronic health record technology (CEHRT), promoting the secure exchange of health information. The foremost intention driving this category is to create a patient-driven healthcare system where patients have the information needed to become active healthcare consumers.
Promoting Interoperability is worth 25 percent of the MIPS final score for most providers. In some cases, a provider may qualify for an exception from this MIPS category. If granted an exception in performance year 2023, the Promoting Interoperability category will be re-weighted to 0 percent, and the Quality performance category will be increased by 25 percent to 55 percent.
The following providers will have automatic re-weighting for the 2023 performance period:
- Clinical social workers
- Physical therapists
- Occupational therapists
- Qualified speech-language pathologists
- Qualified audiologists
- Clinical psychologists
- Registered dieticians or nutrition professionals.
Small practices will also continue to qualify for automatic re-weighting in performance year 2023. There is no need to submit a Promoting Interoperability Hardship Exception application.
MIPS scores assess an eligible clinician’s overall performance in the four MIPS categories compared to the CMS performance threshold score. Eligible clinicians will receive a score in each performance category, which is then weighted accordingly and totaled in their final score. The final MIPS score, which ranges from 0-100 points, will determine the payment adjustment an eligible clinician receives.
The performance threshold defines the score required to earn a neutral to positive payment adjustment for a given year.
- Scores below the performance threshold result in a negative payment adjustment.
- Scores at the performance threshold result in a neutral payment adjustment.
- Scores above the performance threshold result in a positive payment adjustment.
The 2023 MIPS performance threshold remains at 75 points. This is the minimum final score needed to avoid a downward payment adjustment to Medicare Part B claims in 2025.
The 2022 performance year was the last year for an additional performance threshold and/or additional MIPS adjustment for exceptional performance. There will be no option to gain bonus points for the 2023 performance year/2025 payment year.
Based on a provider’s MIPS performance score, a payment adjustment is applied to the Medicare payment of every Part B item and service billed by the provider. The payment adjustment is received in the payment year, two years after the performance year.
CMS estimates that MIPS eligible clinicians who choose not to participate in MIPS lose an average 8.2 percent in Part B reimbursement. That amounts to a hefty sum when you consider an 8.2 percent loss on every Part B item and service billed by a provider. A potential annual Medicare reimbursement of $100,000, for example, becomes $82,000 — minus $18,000 in much-needed revenue. So, here’s the $18,000 question:
What Does MACRA Mean for Physicians?
MACRA rewards physicians for shifting to value over volume through the MIPS track of the QPP and can greatly enhance a clinician’s profit margin through better Medicare reimbursement.
But a clinician’s MIPS score has broader implications that translate into more far-reaching and long-term rewards. It’s vitally important, therefore, for the MIPS clinician and staff — from medical coders and billers to clinical documentation specialists, auditors, and practice managers — to educate themselves every year on updates to the Quality Payment Program final rule.
Understandably, MIPS performance depends on knowledge of ever-evolving MIPS reporting requirements. Without current and reliable MACRA proficiency, a physician’s far-reaching and long-term rewards can fast become far-reaching and long-term penalties. Here’s why.
MIPS Is Competition
MIPS points are scored on a peer-percentile benchmark scale, which essentially means that MIPS clinicians compete against each other, and the winners who score big profit on two fronts — revenue and reputation.
Because MACRA is budget neutral, the law requires MIPS financial penalties to fund MIPS financial rewards. Low-performing MIPS clinicians who earn negative reimbursement adjustments, in other words, pay for the positive incentives their high-performing peers receive.
In the first two years of MACRA, CMS made it relatively easy for MIPS clinicians to avoid penalties. A corollary to this accommodation meant high-performing clinicians received lower than expected incentive payments. In subsequent years, CMS increased the program difficulty and raised reporting requirements. For 2020, this translated into bigger financial gains or losses at stake for MIPS participants.
Still, CMS caps the maximum upward adjustments it awards at three times the maximum negative adjustment, which limits the moneys available for financial rewards. The implications of this raise the bar for high performers. While each point a clinician scores above the performance threshold results in higher incentives, exactly how much one clinician’s score will earn depends on the performance of every clinician.
The only way to ensure you receive the maximum available incentive payment is to recognize the competition factor and ambitiously invest in your MIPS performance. Again, this will require onboarding your team and making sure all staff are fluent in MACRA Year 7, equipped with working knowledge of current MIPS requirements.
MIPS Means PR
MIPS financial rewards extend beyond Part B incentive payments. You could say, in fact, that Part B incentive payments are just the tip of the iceberg in terms of potential revenue gains associated with MIPS performance.
MIPS scores become clinician marketing — free advertising for exceptional performers, as well as potential liability for underperformers.
By law, MACRA requires CMS to publish MIPS final scores and performance category scores on every MIPS participant within 12 months of the performance year through CMS’ online portal, Physician Compare.
In its efforts for optimal transparency — as consumers spend more out-of-pocket for their healthcare — CMS has taken public reporting a step further by making Physician Compare data sets available to third-party physician rating websites. This means your MIPS score will affect patient attraction among all commercial payer populations, as well as Medicare beneficiaries.
What's more, to ensure MIPS performance measures clearly delineate peer-to-peer comparisons, the MACRA Final Rule instituted a 5-star rating system in 2018 to help healthcare consumers accurately interpret the MIPS 100-point performance scale.
As with any business, revenue and reputation go hand in hand. Research demonstrates that online physician reviews drive patient healthcare decisions — that more consumers rely on physician reviews than any other U.S. service or product, according to Harvard Business School. Its analysis of Yelp reviews, for instance, show a 5-9 percent revenue increase linked to each star on a 5-star scale — meaning that a 5-star rating can potentially boost a clinician’s annual revenue by 36 percent.
Voluntarily opting into MIPS, for those whose participation is not mandatory, deserves serious consideration, as the program automatically serves as the frontline initiative of practice marketing and pays in big dividends.
But the risks to underperforming in MIPS are equally substantial, which underscores the need for eligible clinicians to provide their staff with expert MACRA education each year to avert damage to their reputations and ensure they reap the rewards they deserve.
Understand that MIPS scores are irrevocable, a permanent part of public record. Furthermore, CMS ties MIPS scores to the practitioner so that scores follow the practitioner from one practice to another. If, for example, a clinician performs poorly in 2023 and joins a group in 2024, the new group will inherit the clinician’s 2023 performance via his or her 2025 payment adjustment.
MIPS scores, therefore, give clinicians a tremendous advantage or, possibly, a handicap. Performances will not only impact patient attraction and retention but also physician recruiting, contracting, and compensation plans.
Clinicians are included and required to participate in MIPS if they meet all 3 of the following requirements:
- A MIPS eligible clinician type enrolled as a Medicare provider
- Exceed the low-volume threshold
- Are not otherwise excluded (e.g., by achieving QP status)
In 2021, MIPS eligible clinicians required to participate in MIPS could report data as an individual, a group, a virtual group, or an APM Entity:
- Individual: An individual is defined as a single MIPS eligible clinician, identified by a TIN/NPI combination. When you participate as an individual, you collect and report measures and activities based on your individual performance. We assess your performance across all performance categories at the individual level.
- Group: A group is defined as a single TIN with 2 or more clinicians as identified by their NPI who have assigned their Medicare billing rights to the TIN, provided that at least 1 clinician within the group must be MIPS eligible in order for the group to be MIPS eligible. When you participate as a group, the group submits data that’s been aggregated to reflect performance for all the clinicians billing under the TIN as appropriate for the measures and activities selected. We assess your performance across all performance categories at the group level.
- Virtual Group: A virtual group is a combination of 2 or more TINs assigned to one or more solo practitioners or to one or more groups consisting of 10 or fewer MIPS eligible clinicians, or both, that elect to form a virtual group for a performance year. When you participate as a virtual group, the group submits data that’s been aggregated to reflect performance for all the clinicians (across multiple TINs) in the virtual group as appropriate for the measures and activities selected. We assess your performance across all performance categories at the virtual group level.
- APM Entity: An APM Entity is defined as an entity that participates in an Alternative Payment Model or other payer arrangement through a direct agreement with CMS or other payer or through federal or state law or regulation. APM Entities that participate in a MIPS APM can report MIPS data on behalf of the MIPS eligible clinicians in the APM Entity.2 When you participate as an APM Entity, the APM Entity submits quality and improvement activities data that has been aggregated to reflect performance for all the clinicians (sometimes across multiple TINs) in the Entity. Data for the MIPS Promoting Interoperability performance category is submitted at the group and individual level which CMS then aggregates to create an APM Entity score.
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The low-volume threshold is a critical step in determining whether a clinician is included in MIPS for a specific performance year. The low-volume threshold evaluates whether an otherwise MIPS eligible clinician saw an adequate number of eligible patients and provided enough services to meaningfully participate in MIPS. To make this determination, Medicare Part B claims are reviewed for this information for two 12-month segments (referred to as the MIPS Determination Period) to see if a clinician exceeds the low-volume threshold criteria.
For the 2023 performance year, the three criteria of the low-volume threshold that establish MIPS eligibility of approved clinician types are those who:
- Bill Medicare for $90,000 or more in Medicare Part B allowed charges
- Provide care for 200 or more Medicare Part B beneficiaries
- Provide 200 or more Medicare Part B covered professional services under the MPFS.
Groups or virtual groups with one or more MIPS eligible clinicians are also eligible. Additionally, clinicians who meet or exceed one or two of the low-volume threshold criteria can opt in to participate in MIPS. :::
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a law that reformed the Medicare payment system. MACRA repealed the Sustainable Growth Rate (SGR) formula used to update the Medicare Physician Fee Schedule (MPFS) and thereby determine physician reimbursement. The SGR was replaced with a “value-based” payment system that incorporates quality measurement into payments with the goal of creating an equitable payment system for physicians. MACRA also reauthorized the Children’s Health Insurance Program (CHIP).
On April 16, 2015, President Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015 — the largest change to the American healthcare system since the Affordable Care Act of 2010. Overwhelmingly endorsed by Democrats and Republicans in an uncommon moment of bipartisanship in Congress, MACRA ended the way Medicare Part B providers were disadvantageously reimbursed through the SGR.
MACRA is known as the Permanent Doc Fix because it revised the flawed 1997 Balanced Budget Act,which resulted in exorbitant reimbursement reductions that incited physicians to threaten to leave the Medicare program.
From 2002 to the enactment of MACRA in 2015, Congress voted 17 times to delay the implementation of the SGR to prevent SGR-calculated cuts from taking place. If not for the enactment of MACRA, the Medicare program—as well as persons who rely on it to receive medical care—would have been at risk.
By law, MACRA required the Centers for Medicare & Medicaid Services (CMS) to establish value-based healthcare business models that link an ever-increasing portion of physician payments to service-value rather than service-volume. These incentive-based business models, collectively referred to as the Quality Payment Program (QPP), provide two participation tracks for eligible clinicians — the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs)—both of which involve levels of financial rewards and risks.
Unlike previous quality initiatives, participation in the QPP does not require providers to enroll. Eligible clinicians need only choose which track they prefer—MIPS or Advanced APMs—based on their practice size, specialty, location, and patient population.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA):
- repealed the sustainable growth rate (SGR) formula used to update the Medicare Physician Fee Schedule (MPFS)
- reauthorized the Children’s Health Insurance Program (CHIP) and
- changed the way Medicare incorporates quality measurement into payments.
Together, these policies are referred to as the Quality Payment Program (QPP). The SGR was enacted under the Balanced Budget Act of 1997 to control Medicare spending. The flaw in the system was that physicians’ payment rates under the rule dropped so low that the SGR had to be suspended or adjusted by Congress every year to prevent physicians from opting out of Medicare. MACRA provided automatic, annual update to the single conversion factor of 0.5 percent for all physicians and other qualified healthcare professionals through 2019. Medicare Part B payment rates will stay frozen at 2019 levels through 2025. Beginning in 2019, eligible clinicians (defined later) will either receive negative, neutral, or positive adjustments to their Medicare Part B payments based on their performance in the Merit-Based Incentive Payment System (MIPS) or a MIPS Alternative Payment Model (APM), or earn a lump sum bonus for participation in an Advanced Alternative Payment Model (APM). Under MACRA, Medicare’s costly and complex quality initiatives — the Physician Quality Reporting System (PQRS), the Value‐Based Modifier Program (VM), and the Medicare Electronic Health Record (EHR) Incentive Program, also known as Meaningful Use — ended on Dec. 31, 2018. Components of the PQRS, VM, and Meaningful Use programs live on in MIPS, however.
The overarching goal of the QPP is to implement a patient-centered healthcare system that delivers better care, smarter spending, and healthier people. In theory, increasing the health of our population will reduce medical costs and preserve Medicare’s main trust fund, which is on track to run dry by 2026.
The bedrock of the QPP is “high-value, patient-centered care, informed by useful feedback, in a continuous cycle of improvement.” Quality care is tied to medical coding and medical coding is tied to reimbursement. The days of siloed expertise is a thing of the past and we must understand how each area of revenue cycle management (RCM) affects the next. Coders have a unique ability to understand how RCM works for both the physician and payer. To have a coder on the team who also understands the QPP is essential for clinicians who wish to receive full credit for the quality care they provide to patients.
The QPP is comprised of two payment methodologies:
- Merit-Based Incentive Payment System (MIPS)
- Advanced Alternative Payment Models (APMs)
Although there are two separate pathways within the QPP, both Advanced APMs and MIPS contribute toward the goal of seamless integration of the QPP into clinical practice workflows: Advanced APMs promote seamless integration by way of payment methodology and design that incentivize care coordination; and MIPS builds on the capacity of eligible clinicians to participate in APMs in later years of the QPP.
CMS published a final rule in 2016 to establish special policies for year 1 (performance year 2017/payment year 2019) of the QPP. The Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models final rule, or 2017 QPP final rule, established:
- Incentives for participation in Advanced APMs
- The definition and processes for Qualifying APM Participants (QPs) in Advanced APMs
- Criteria for use of the Physician-Focused Payment Model Technical Advisory Committee (PTAC) and
- Policies to phase in the implementation of MIPS
The 2018 QPP final rule further implemented policies established in the 2017 QPP final rule, and addressed elements of MACRA that were not included in the first year of the program, including:
- Virtual groups
- 2019 performance period facility-based measurement
- Improvement scoring
Added flexibilities were offered to small practices to alleviate perceived burden and several bonus opportunities were added to encourage participation.
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2017 was a memorable year. Hurricanes tore through entire communities in Florida and Puerto Rico and fires blazed through California, leaving entire communities without water, electricity, and shelter. CMS released an interim final rule concurrently with the 2018 QPP final rule to establish an automatic extreme and uncontrollable circumstance policy for year 1 of MIPS to recognize the 2017 hurricanes and other natural disasters that impeded many MIPS eligible clinicians’ ability to participate in the QPP. In short, CMS applied the extreme and uncontrollable circumstances policies for all MIPS eligible clinicians in affected areas without requiring an application to be submitted. These MIPS eligible clinicians received a final score equal to the 2017 performance threshold. :::
A third final rule, published in the Nov. 23, 2018, Federal Register, further implemented MACRA mandates and revised several previously finalized policies for year 3 (performance year 2019/payment year 2021) of the QPP.
Notable changes included:
- An expanded list of eligible clinician types
- An opt-in to MIPS option
- A third criterion to the low-volume threshold calculation
- Weight changes to the Quality and Cost performance categories
According to CMS, 99.99 percent of eligible clinicians participated in MIPS in 2019 with 954,614 eligible clinicians receiving a payment adjustment. Of those who received a payment adjustment, 97.6 percent received a positive payment adjustment for payment year 2021 based on their performance in 2019.
Also, for the 2019 performance period, CMS reports that 195,564 eligible clinicians earned Qualifying APM Participant (QP) status, while another 27,995 eligible clinicians earned partial QP status.
Due to the public health emergency (PHE) for the COVID-19 pandemic, CMS reports that 65,237 (approximately 6.83 percent of 954,614) MIPS eligible clinicians received reweighting of one or more MIPS performance categories for year 3 under the MIPS Extreme and Uncontrollable Circumstances policy.
The 2020 QPP final rule continued to phase in previously finalized policies for year 4 (performance year 2020/payment year 2022) and introduced a radical change to how clinicians will select measures in the future. Notable changes to the QPP for year 4 include:
- Weight changes to the Quality and Cost performance categories
- Payment threshold changes
- Payment adjustment changes
- Definition of hospital-based clinicians
- Proposed MIPS Value Pathways (MVP)
Due to the PHE for the COVID-19 pandemic, however, CMS finalized in the 2021 QPP final rule several changes to year 4 policy:
- An increase to the complex patient bonus. Clinicians, groups, virtual groups, and APM entities can earn up to 10 bonus points toward their final score for the 2020 performance year, only.
- APM entities may apply for reweighting of MIPS performance categories due to extreme and uncontrollable circumstances for the 2020 performance year, only. If approved, the APM entity will receive a score equal to the performance threshold.
- An extension for applying for reweighting due to extreme and uncontrollable circumstances for the 2019 performance period from Dec. 31, 2019, to Feb. 1, 2020.
In separate rulemaking, CMS also added a new COVID-19 Clinical Trials improvement activity to the CY 2020 Improvement Activities inventory for use beginning with the 2020 performance period.
Not every healthcare provider is required to participate in the Quality Payment Program (QPP). First and foremost, payment adjustments only apply to professional services paid under Medicare Part B, so providers who don’t accept Medicare Part B are excluded.
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For the 2018 performance year, CMS defined eligible clinicians (identified by a unique billing Tax Identification Number (TIN) and National Provider Identifier (NPI) combination) as any of the following healthcare professionals:
- Certified Registered Nurse Anesthetists (CRNA)
- Clinical Nurse Specialists (CNS)
- Doctors of Chiropractic (DC)
- Doctors of Dental Medicine (DMD)
- Doctors of Dental Surgery (DDS)
- Doctors of Medicine (MD)
- Doctors of Optometry (OD)
- Doctors of Osteopathy (DO)
- Doctors of Podiatric Medicine (DPM)
- Nurse Practitioners (NP)
- Physician Assistants (PA)
For performance year 2019, CMS expanded this list to include the following eligible clinicians for the purposes of MIPS participation:
- Clinical Psychologists
- Physical Therapists
- Occupational Therapists
- Qualified Speech-Language Pathologists
- Qualified Audiologists
- Registered Dietitian or Nutrition Professionals
This list is unchanged for year 5 (performance year 2021/payment year 2023). :::
All MIPS eligible clinicians, including those in a MIPS APM, may participate in MIPS as an individual, group, virtual group, or (new for 2021) an APM entity.
The above-listed clinician types are automatically considered eligible clinicians if they meet or exceed the low-volume threshold. Beginning with performance year 2019, a MIPS eligible clinician:
- Earns more than $90,000 in Medicare Part B allowed charges; and
- Sees more than 200 Medicare Part B patients; and
- Provides more than 200 covered professional services under the Medicare Physician Fee Schedule (MPFS).
CMS estimates approximately 228,000 clinicians will be MIPS eligible because they exceed the low volume threshold as individuals and are not otherwise excluded. CMS identifies these clinicians as having “required eligibility.” Of those required to participate, CMS estimates 27,115 (10%) will choose not to participate.
As in performance year 2020, eligible clinicians who do not meet all three criteria are excluded from MIPS but may voluntarily report. Voluntary reporters do not receive payment adjustments and their performance results will not be published on the CMS Physician Compare website if they choose to opt out. The advantage of voluntary reporting is to generate feedback reports the clinician/group can use to prepare for future participation in the QPP; it also helps CMS improve the accuracy of benchmarks used to evaluate measures.
Beginning in 2019, eligible clinicians who meet at least one criterion (but not all three) may opt-in to MIPS. For example, an eligible clinician who receives $90,000 in allowed Medicare charges but sees fewer than 200 patients and provides fewer than 200 professional services may opt-in to MIPS. Those who opt in are considered MIPS eligible clinicians and will receive payment adjustments based on performance.
MIPS eligibility is based on two consecutive 12-month lookback periods that align with the fiscal year, beginning on Oct. 1. For 2021, the two determination periods are Oct. 1, 2019, to Sept. 30, 2020, and Oct. 1, 2020, to Sept. 30, 2021. Eligibility for the upcoming performance period is based on only the first 12-month period.
An eligible clinician may also be excluded from MIPS payment adjustments if one or more of the following is true:
- The clinician is a Medicare freshman.
- The clinician is a Qualifying APM Participant (QP) or Partial QP (PQP) in an Advanced APM.
There are automatic exclusions (based on the low volume threshold) from MIPS and then there are exceptions, which may or may not require application. For example, MIPS eligible clinicians without access to certified electronic health record technology (CEHRT) due to a significant hardship, such as decertification of their electronic health record (EHR), can apply to have the Promoting Interoperability (formerly Advancing Care Information) category reweighted to zero (the weight is then transferred to the Quality performance category).
For performance year 2018, CMS added a significant hardship exception from the Promoting Interoperability performance category for MIPS eligible clinicians in small practices. To apply for a significant hardship for performance year 2021, clinicians had to submit a significant hardship application to CMS by Dec. 31, 2020. CMS makes other exceptions for small practices, practices located in rural areas; non-patient-facing individual MIPS eligible clinicians or groups; and individual MIPS eligible clinicians and groups that participate in a MIPS APM or a patient-centered medical home. To date, CMS has not imposed a time limitation for the number of years a clinician can apply for a significant hardship exception.
For the 2021 performance period, there are no changes to this policy for individual clinicians, groups, and virtual groups. However, beginning with the 2020 performance period, APM entities may also apply for reweighting of all MIPS performance categories. APM entity groups will receive a score equal to the performance threshold even if data are submitted. As in previous years, however, individual clinicians, groups, and virtual groups that submit data override the approved reweighting on a category-by-category basis. For performance years 2021 and 2022, the minimum Quality performance score for an ACO affected by an extreme and uncontrollable circumstance during the performance year will be set equal to the 30th percentile MIPS Quality performance category score. CMS states in the 2021 QPP final rule, “If an ACO is unable to report quality data and meet the MIPS Quality data completeness and case minimum requirement due to an extreme and uncontrollable circumstance, we will apply the 30th percentile MIPS Quality performance category score.”
Note: CMS states in the 2021 MPFS final rule that it anticipates the PHE for COVID-19 to continue into and through CY 2021. As such, the extreme and uncontrollable circumstances policy will be available for the 2021 performance period.
Remember: if a clinician, group, or virtual group submits data for the 2021 performance period, the data submission overrides the application and the clinician, group, or virtual group will be scored on the data submitted.
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Revenue
A clinician who is not eligible to participate in MIPS is not subject to MIPS payment adjustments — good or bad. However, clinicians who voluntarily report data will receive a feedback report from CMS, allowing them to see how their performance may affect future payments.
Marketing
CMS allows a 30-day “opt-out” period for low-volume eligible clinicians to voluntarily submit data and not have the information become public. Unfortunately, they will not know how they did and whether they should opt out for several months later, when CMS releases performance feedback. :::
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Revenue
Both tracks in the QPP have levels of financial risks and rewards.
Marketing
CMS will publish MIPS eligible clinicians’ performance scores on its Physician Compare website11. This free website is used by patients and consumer rating websites. Exceptional performers will benefit from this free advertising. The same cannot be said for underperformers. CMS will publish final scores a year after data is reported, giving clinicians time to preview their performance data and, if appropriate, request a targeted review before it is made public. Clinicians will be rated on a scale of 0 to 100 and how they compare to peers nationally. A 2014 JAMA study found that 65 percent of consumers are aware of online physician rating sites and 36 percent of consumers have used a ratings site at least once. High performance scores and ratings can become a strategic marketing advantage for providers over their competitors who have low or no scores.
Future Options to Join a Group
If a clinician’s MIPS performance feedback scores are low, their ability to join a new group or hospital may be compromised. Potential employers will not want to inherit a clinician’s low score and risk lowering their score. :::
The timeline for QPP performance and payment adjustments spans three years. For example:
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"Performance Year" = c(2017:2023),
"Submission Year" = c(2018:2024),
"Payment Year" = c(2019:2025)) |>
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Clinicians collect data during the performance year; submit the data to CMS between January 1 and March 31 the following year, receive performance feedback by July that year; and receive payment adjustments based on performance the following year. Scheduled MIPS payment adjustments and potential bonuses for Qualifying APM Participants (QP) and Partial Qualifying APM Participants (PQP) in an Advanced APM are shown in the table below.
When a clinician has multiple final scores associated with a single TIN/NPI combination, CMS will use a virtual group final score first to determine the 2023 payment year MIPS payment adjustment and the highest available final score from the APM entity, group, or individual second. This is changed from 2022 payment year policy, in which the APM entity final score will be considered first.
To receive a neutral payment adjustment to Medicare Part B claims in 2023, MIPS eligible clinicians will need to earn a final score of 60 points, the performance threshold for year 5. This is a change from the 45-point threshold in year 4. The additional performance threshold for exceptional performance is 85 points (up from 80 points in 2020). Note, however, that year 4 was the final year for additional positive adjustments for exceptional performance.
MIPS is budget neutral, which means CMS takes the money it saves from providers who receive reductions to pay for provider who receive increases. The maximum upward adjustment is capped at three times the maximum negative adjustment.
CMS discontinued awarding measure bonus points to CMS Web Interface reporters for reporting high priority measures in performance year 2019. Beginning in 2019 and through the 2023 MIPS payment year, the total measure bonus points for high priority measures cannot exceed 10 percent of the total available measure achievement points. Beginning with payment year 2023, bonus points for the Query of Prescription Drug Monitoring Programs (PDMP) measure are increased from 5 points to 10 points, based on 2021 performance.
CMS will apply a complex patient bonus capped at 5 points to the final score for the 2021 MIPS performance period/2023 MIPS payment year. Complexity is measured through hierarchical condition category (HCC) risk scores and social risk as measured through the proportion of patients with dual eligible status.
HCC risk scores are calculated annually, based on the following information from the calendar year:
- Patient’s age and gender;
- Patient’s eligibility for Medicaid, disabled, or lives in an institution; and
- Patient’s diagnoses.
The formulas used to calculate the bonuses are:
-
MIPS eligible participants: [the average HCC risk score assigned to beneficiaries seen by the MIPS eligible clinician or seen by clinicians in a group] + [the dual eligible ratio x 5].
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APM entities: [the beneficiary weighted average HCC risk score for all MIPS eligible clinicians, and if technically feasible, TINs for models and virtual groups which rely on complete TIN participation within the APM entity or virtual group, respectively] + [the average dual eligible ratio for all MIPS eligible clinicians, and if technically feasible, TINs for models and virtual groups which rely on complete TIN participation, within the APM entity or virtual group, respectively, x 5].
Note: The QPP is budget neutral so all figures are variable, depending on the number of providers sharing the $500 million MACRA provided for this purpose.
Small practices face challenges in their ability to participate in MIPS. CMS encourages small practices to participate by subsidizing some of their infrastructure hurdles. CMS states in the 2018 QPP final rule, “The support of small, independent practices remains an important thematic objective for the implementation of the Quality Payment Program and is expected to be carried throughout future rulemaking.” CMS defines small practices for the purposes of MIPS as 15 or fewer clinicians. As in previous years, CMS continues to award 6 bonus points in the Quality performance category to MIPS eligible clinicians in small practices who submit data on at least one measure and 3 points for quality measures that don’t meet data completeness requirements. Additionally, clinicians in small practices may apply to have the Promoting Interoperability performance category reweighted to zero. Small practices also have reduced reporting requirements in the Improvement Activities category:
- Medium-weighted activities are worth 20 points; and
- High-weighted activities are worth 40 points
CMS also offers free and customized resources available within local communities, including direct, one-on-one support from the Small, Underserved, and Rural Support Initiative, in addition to CMS’ other no-cost technical assistance. Beginning with the 2019 performance period (year 3), only small practices — whether participating individually or as a group — may submit quality measures using Medicare Part B claims as a submission type. Lastly, small practices may continue to participate in MIPS as a virtual group.
Beginning with the 2019 performance period, clinicians may participate in MIPS as an individual, as a group, as an APM entity in a MIPS APM, or as a virtual group. A virtual group is a combination of two or more TINs assigned to one or more solo practitioners or one or more groups consisting of 10 or fewer eligible clinicians that elect to form a virtual group for a performance period for a year. If a group chooses to join a virtual group, all of the clinicians in that group are part of the virtual group. The group’s final score and resulting payment adjustment percentage applies to all clinicians in the virtual group. The virtual group eligibility determination period aligns with the first period of data analysis under the MIPS eligibility determination period. For year 5, the determination period is Oct. 1, 2019, to Sept. 30, 2020 (including a 30-day claims run out).
A virtual group election is considered a low-volume threshold opt-in for any prospective member of the virtual group that exceeds at least one, but not all three, of the low-volume threshold criteria. Clinicians can only participate in one virtual group per performance period. There is no limit on the size of a virtual group12. Virtual groups are held to the same requirements for each performance category as standard groups, and are responsible for aggregating data for their measures and activities across the virtual group. TINs can inquire about their TIN size prior to making an election during a 3-month time frame, which begins Oct. 1 and ends Dec. 31 of the calendar year prior to the applicable performance period.
There is a two-stage election process for virtual groups:
Stage 1 (optional): If you’re a solo practitioner or part of a group with 10 or fewer eligible clinicians:
- Make any formal written agreements.
- Send in your formal election registration.
- Budget your resources for your virtual group.
Stage 2 (required): The virtual group must have a formal agreement between each solo practitioner and group that composes the virtual group prior to submitting an election to CMS. Each virtual group must name an official representative who is responsible for submitting the virtual group’s election. Elections must be submitted via e-mail to [email protected] by December 31 of the preceding year you intend to operate as a virtual group. The data submission criteria applicable to groups are also generally applicable to virtual groups, except for data completeness and sampling requirements for the CMS Web Interface and CAHPS for MIPS survey:
- Data completeness for virtual groups applies cumulatively across all TINs in a virtual group. There may be a case when a virtual group has one TIN that falls below the 60 percent data completeness threshold, which is an acceptable case as long as the virtual group cumulatively exceeds such threshold.
- The CMS Web Interface and CAHPS for MIPS survey sampling requirements pertain to Medicare Part B patients with respect to all TINs in a virtual group, where the sampling methodology will be conducted for each TIN within the virtual group and then cumulatively aggregated across the virtual group. A virtual group would need to meet the beneficiary sampling threshold cumulatively as a virtual group.
#| echo: false
dplyr::tibble(
Year = "Performance Year",
NPI = "National Provider Identifier assigned to the clinician. Multiple rows for the same NPI indicate multiple TIN/NPI combinations.",
State = "State or US territory location of the TIN associated with the clinician.",
"Practice Size" = "Count of clinicians associated with TIN from the second segment of the MIPS eligibility determination period.",
Specialty = "Identifier corresponding to the type of service that the clinician submitted most on their Medicare Part B claims for this TIN/NPI combination.",
"Years in Medicare" = "The number of years since the first date an enrollment was approved for this NPI across all enrollments in PECOS.",
"Participation Type" = "Indicates the level at which performance data was collected, submitted or reported for the final score attributed to the clinician.",
Beneficiaries = "Number of Medicare patients who received covered professional services during one segment of the MIPS eligibility determination period attributed to the participation type associated with the clinician’s final score.",
Charges = "Allowed charges under the Physician Fee Schedule on Medicare Part B claims with a service date during one segment of the MIPS eligibility determination period attributed to the Participation Type associated with the clinician’s final score.",
Services = "Number of covered professional services provided to Medicare Part B patients with a service date during one segment of the MIPS eligibility determination period attributed to the Participation Type associated with the clinician’s final score.",
## SCORES
"Final Score" = "The MIPS final score attributed to the clinician (the highest final score that could be attributed to the clinician’s TIN/NPI combination). ",
"Payment Adjustment" = "The total payment adjustment attributed to the clinician for the 2023 payment year. Payment adjustments are determined by comparing the final score to the performance thresholds, and then scaled to ensure budget neutrality.",
"Complex Patient Bonus" = "The complex patient bonus associated with the final score attributed to the clinician.",
"Quality Score" = "This is the unweighted score received for the quality score that is used for the overall score.",
"Quality Bonus" = "The bonus points received for the quality category (small practice bonus and quality improvement, if applicable).",
"Promoting Interoperability Score" = "This is the unweighted score received by the participant for the Promoting Interoperability performance category, the score that is used for the final score. MIPS APM participants receive their APM Entity roll-up score unless this category was reported by the APM Entity.",
"Improvement Activities Score" = "The score received for the improvement activities performance category based on all the activities picked for the category that contributed to the final score.",
"Cost Score" = "The unweighted score received for the cost performance category based on all the cost measures used for final scoring. Will display as “0” for 2021 as cost was reweighted in the 2021 performance year.",
## BOOLEANS
Engaged = "Indicates if the clinician reported a minimum of one measure or activity as an individual or group, OR participated in a MIPS APM.",
"Opted into MIPS" = "Indicates if an Opt-In Eligible clinician or group elected to participate in MIPS and receive a payment adjustment. An Opt-In Eligible clinician or group is one that is otherwise eligible for MIPS and exceeds 1 or 2, but not all 3 low-volume threshold criteria",
"Small Practitioner" = "Indicates if the clinician or group had the small practice special (15 or fewer clinicians billed under the TIN) based on either segment of the MIPS eligibility determination period. Note: This number can contradict the Practice Size column which is always based on the 2nd segment.",
"Rural Clinician" = "Indicates if the clinician or group had the rural special status (practiced in a ZIP code designated as rural by the Federal Office of Rural Health Policy (FORHP) using the most recent FORHP Eligible ZIP code file available).",
"HPSA Clinician" = "Indicates if the clinician or group had the HPSA special status (practiced in a Health Professional Shortage Area (HPSA).",
"Ambulatory Surgical Center" = "Indicates if the clinician or group had the ambulatory surgical center-based special status (determined by the volume of their covered professional services furnished in an ambulatory surgical center.)",
"Hospital-Based Clinician" = "Indicates if the clinician or group had the hospital-based special status (determined by the volume of their covered professional services furnished in a hospital setting).",
"Non-Patient Facing" = "Indicates if the clinician or group has the non-patient facing special status (determined by volume of Medicare Part B patient-facing encounters, including telehealth services).",
"Facility-Based" = "Indicates if the clinician or group has the facility-based special status (based on volume of services furnished in a facility eligible for the Hospital Value-based Purchasing program).",
"Extreme Hardship" = "Indicates if the clinician, group or APM Entity was affected by an extreme and uncontrollable circumstance (EUC) (such as FEMA-designated major disaster) and qualified for performance category reweighting because of the MIPS automatic EUC policy or MIPS EUC exception application.",
"Extreme Hardship Quality" = "Indicates if the clinician, group or APM Entity was approved for reweighting of the quality performance category due to extreme and uncontrollable circumstances.",
"Extreme Hardship PI" = "Indicates if the clinician, group or APM Entity was approved for reweighting of the Promoting Interoperability performance category due to extreme and uncontrollable circumstances.",
"PI Hardship" = "Indicates if the clinician or group was approved for an exception from the Promoting Interoperability performance category due to participation in a small practice, decertified Electronic Health Record (EHR) technology, insufficient Internet connectivity, or lack of control over the availability of certified EHR technology (CEHRT).",
"PI Reweighting" = "Indicates if the clinician or group qualified for an automatic reweighting from the Promoting Interoperability performance category due to special status or clinician specialty.",
"PI Bonus" = "The total bonus points received by the clinician, group or APM Entity for the Promoting Interoperability performance category.",
"Extreme Hardship IA" = "Indicates if the clinician, group or APM Entity was approved for reweighting of the improvement activities performance category due to extreme and uncontrollable circumstances.",
"IA Study" = "This data element will show as FALSE for everyone because this study concluded after the 2019 performance year.",
"Extreme Hardship Cost" = "Indicates if the clinician or group was approved for reweighting of the cost performance category due to extreme and uncontrollable circumstances. Not applicable for 2021; this category was reweighted for all individuals and groups.",
## INDIVIDUAL MEASURE SCORES
"Quality Measure ID" = "MIPS Quality ID for one of 10 possible quality measures that contributed to the final score.",
"Quality Measure Score" = "Score (plus bonus points) achieved for corresponding MIPS Quality ID that contributed to the final score.",
"PI Measure ID" = "MIPS Promoting Interoperability ID for one of 11 possible Promoting Interoperability measures that contributed to the final score.",
"PI Measure Score" = "Measure score achieved for the corresponding MIPS Promoting Interoperability ID that contributed to the final score.",
"IA Measure ID" = "MIPS Improvement Activity ID for one of 4 possible improvement activities that contributed to the final score.",
"IA Measure Score" = "Activity score achieved for the corresponding MIPS Improvement Activity ID that contributed to the final score.",
"Cost Measure ID" = "MIPS Cost ID for one of 2 possible cost measures that contributed to the final score. Not applicable for 2021; this category was reweighted for all individuals and groups.",
"Cost Measure Score" = "Cost score achieved for the corresponding MIPS Cost ID that contributed to the final score. Not applicable for 2021; this category was reweighted for all individuals and groups.",
"PI CEHRT ID" = "This is a unique identifier generated by the Office of the National Coordinator for Health Information Technology (ONC) and identifies a specific bundle of software or EHR. The CEHRT ID is a 15-character alpha-numeric string which can be found on the CHPL website. This is the CEHRT ID included in the data that contributed to the clinician’s final score.") |>
tidyr::pivot_longer(
cols = dplyr::everything(),
names_to = "Field",
values_to = "Description") |>
dplyr::mutate(col = dplyr::row_number(), .before = Field) |>
gt::gt(rowname_col = "col") |>
gt::tab_header(title = gt::md("**Quality Payment API** Data Dictionary")) |>
gt::opt_align_table_header("left") |>
gt::opt_stylize(color = "red") |>
gt::tab_source_note(source_note = gt::md("If **Participation Type** = `Group`, Beneficiaries are attributed to the TIN, not the Individual Clinician. If **Participation Type** = `APM Entity`, fields related to the Low-Volume Threshold and Special Status (columns 9 – 19) are attributed to the Clinician’s Group (TIN), not the APM Entity. Beginning in 2021, CMS won’t evaluate APM Entities for the Low-Volume Threshold."))
library(provider)
library(tidyverse)
abbott_qpp <- 2017:2021 |>
map(\(x) quality_payment(
year = x,
npi = 1730455775)) |>
list_rbind()
abbott_qpp |>
select(year,
npi,
part_type,
specialty,
beneficiaries,
allowed_charges,
services,
pmt_adj_pct) |>
gt::gt(rowname_col = "year") |>
gt::fmt_number(
columns = c(beneficiaries,
allowed_charges,
services), decimals = 0) |>
gt::cols_label(part_type = "PARTICIPATION",
allowed_charges = "CHARGES",
pmt_adj_pct = "PAYMENT ADJUSTMENT") |>
gt::opt_stylize(color = "red") |>
gt::text_transform(fn = toupper,
locations = gt::cells_column_labels())
abbott_qpp |>
select(year,
Final = final_score,
Quality = quality_category_score,
"Performance Improvement" = pi_category_score,
"Improvement Activities" = ia_score,
Cost = cost_score,
complex_patient_bonus,
quality_improvement_bonus)
abbott_measures <- abbott_qpp |>
select(year, contains("quality_measure")) |>
pivot_longer(!year, names_to = "type", values_to = "val") |>
separate_wider_delim(type, "_", names = c("category", "m", "type", "group")) |>
mutate(m = NULL) |>
pivot_wider(names_from = type, values_from = val, values_fn = list) |>
unnest(cols = c(id, score)) |>
filter(!is.na(id))
abbott_measures
measures_2019 <- jsonlite::fromJSON("C:/Users/andyb/Desktop/provider_book/data/measures-data_2019.json") |>
mutate(year = 2019,
submissionMethods = NULL,
eMeasureUuid = NULL,
substitutes = NULL,
.before = title) |>
unnest(cols = c(reportingCategory))
measures_2019 |>
count(category)
abbott_measures |>
left_join(measures_2019,
by = join_by(year, category, id == measureId)) |>
janitor::remove_empty(which = c("rows", "cols")) |>
mutate(group = NULL)
hussain_qpp <- 2017:2021 |>
furrr::future_map(\(x) quality_payment(
year = x,
npi = 1043477615)) |>
purrr::list_rbind()
hussain_qpp |>
select(year,
final_score,
practice_size,
part_type,
beneficiaries,
allowed_charges,
services,
pmt_adj_pct,
complex_patient_bonus,
quality_category_score,
quality_improvement_bonus,
pi_category_score,
ia_score,
cost_score) |>
provider:::gt_prov()
hussain_qpp |>
select(year,
contains("quality_measure")) |>
tidyr::pivot_longer(!year,
names_to = "type",
values_to = "val") |>
tidyr::separate_wider_delim(type, "_",
names = c("q", "m", "type", "qm_no")) |>
tidyr::unite("name",
c("q", "m"),
remove = TRUE,
sep = " ") |>
tidyr::pivot_wider(names_from = type,
values_from = val,
values_fn = list) |>
tidyr::unnest(cols = c(id, score)) |>
filter(!is.na(id))
#| echo: false
#| eval: false
qpp_ga <- 2017:2021 |>
furrr::future_map(\(x) quality_payment(year = x,
state = "GA",
specialty = "Internal Medicine",
part_type = "Individual")) |>
purrr::list_rbind()
#| echo: false
#| eval: false
qpp_ga |>
select(year,
npi,
contains("quality_measure")) |>
tidyr::pivot_longer(!c(year, npi),
names_to = "type",
values_to = "val") |>
tidyr::separate_wider_delim(type, "_",
names = c("q", "m", "type", "qm_no")) |>
tidyr::unite("name",
c("q", "m"),
remove = TRUE,
sep = " ") |>
tidyr::pivot_wider(names_from = type,
values_from = val,
values_fn = list) |>
tidyr::unnest(cols = c(id, score)) |>
filter(!is.na(id))
#| echo: false
#| eval: false
qpp_ga |>
select(year,
npi,
contains("pi_measure")) |>
tidyr::pivot_longer(
!c(year, npi),
names_to = "type",
values_to = "val") |>
tidyr::separate_wider_delim(
type, "_",
names = c("q", "m", "type", "qm_no")) |>
tidyr::unite("name",
c("q", "m"),
remove = TRUE,
sep = " ") |>
tidyr::pivot_wider(names_from = type,
values_from = val,
values_fn = list) |>
tidyr::unnest(cols = c(id, score)) |>
filter(!is.na(id))
#| echo: false
#| eval: false
qpp_ga |>
select(year,
npi,
final_score,
#practice_size,
#part_type,
#beneficiaries,
#allowed_charges,
#services,
pmt_adj_pct,
complex_patient_bonus,
quality_category_score,
quality_improvement_bonus,
pi_category_score,
ia_score,
cost_score) |>
group_by(npi) |>
provider:::gt_prov()