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The MIPS mess

February 3, 2020

Topics: Quote of the Day

By Elizabeth Woodcock, MBA, FACMPE, CPC
Medscape, January 29, 2020

If you’ve knocked yourself out to earn a Merit-based Incentive Payment System (MIPS) bonus payment, it’s pretty safe to say that getting a 1.68% payment boost probably didn’t feel like a “win” that was worth the effort.

And although it saved you from having a negative 5% payment adjustment, many physicians don’t feel that it was worth the effort.

Based on 2018 participation, the bonus for those who scored a perfect 100 is only a 1.68% boost in Medicare reimbursement, slightly lower than last year’s 1.88%.

Overall, more than 97% of participants avoided having a negative 5% payment adjustment.

Indeed, these bonus monies are based on a short-term appropriation of extra funds from Congress. After these temporary funds are no longer available, there will be little, if any, monies to distribute as the program is based on a “losers-feed-the-winners” construct.

It may be very tempting for many physicians to decide to ignore MIPS, with the rationale that 1.68% is not worth the effort. But don’t let your foot off the gas pedal yet, since the penalty for not participating in 2020 is a substantial 9% (in perpetuity). Physicians should make sure that they, at minimum, achieve the 45 points necessary to avoid that pitfall this reporting year.

Physicians are spending a significant amount of money to comply with the program requirements. This includes substantial payments to registries—typically $200 to >$1000 per year—to report the quality measures for the program; electronic health record (EHR) systems, many of which require additional funding for the “upgrade” to a MIPS-compatible system, are also a sizable investment.

These hard costs pale in comparison with the time spent on understanding the ever-changing requirements of the program and the process by which your practice will implement them.

(Electronic Referral Loops) is only one of more than a dozen required elements: six quality measures, two (to four) improvement activities, and four promoting interoperability requirements. Each one of these elements has a host of requirements, all listed on multipage specification sheets.

In 2020, the threshold to avoid the penalty is 45 points. In order to get the 45 points, practices must participate in two improvement activities, which is not difficult as there are 118 options. That will garner 15 points. Then there are 45 points available from the quality category; you need at least 30 to reach the 45-point threshold for penalty avoidance.

To obtain the additional 30 points, turn your attention to the quality category. There are 268 quality measures; choose at least six to measure. If you report directly from your EHR system, you’ll get a bonus point for each reported measure, plus one just for trying.

The quality category has a total of 100 points available, which are converted to 45 toward your composite score. Since you need 30 to reach that magical 45 (if 15 were attained from improvement activities), that means you must come up with 75 points in the quality category.

There are two other categories in the program: promoting interoperability (PI) and cost. The PI category mirrors the old “meaningful use” program; however, it has become increasingly difficult over the years. If you think that you can meet the required elements, you can pick up 25 more points toward your composite score.

Cost is a bit of an unknown, as the scoring is based on a retrospective review of your claims. You’ll likely pick up a few more points on this 15-point category, but there’s no method to determine performance until after the reporting period. Therefore, be cautious about relying on this category.

MIPS is not going anywhere; the program is written into the law.

But that doesn’t mean that CMS can’t make tweaks and updates. Hopefully, the revisions won’t create even more administrative burden as the program is quickly turning into a big stick with only a small carrot at the end.


Explaining MIPS

Comment by Don McCanne, M.D.
Quote of the Day, March 2015

On reading the summary of the “SGR Repeal and Medicare Provider Payment Modernization Act,” you will see that MIPS places a tremendous administrative burden on health care professionals in a health care system that is already overwhelmingly overburdened with administrative excesses. The only way to escape this additional burden is to participate in Alternative Payment Models (APMs) which, in themselves, create further significant administrative burdens (ACOs, PCMHs, etc.). MIPS is an administrative nightmare.

Under the MIPS payment system, eligible professionals with higher scores will receive positive payment adjustments (and may be eligible for an additional incentive payment). We have observed repeatedly how such systems are gamed in order to receive these extra payments. The problem is that those who do not game the system, and especially those with practice situations and patient populations that make it very difficult to score higher points, will almost automatically receive performance scores below the threshold since their performances will be compared with the gamers. This will result in negative payment adjustments – reducing payments by up to nine percent.

This is serious. And it is being steamrolled through Congress right now! Those who care about the future of Medicare and who do have organizational skills must immediately inform themselves on what is happening here. Then act. You cannot wait to watch the Congressional vote tally on C-Span, perhaps as early as this week (2015). By then it will be a done deal.



By Don McCanne, M.D.

There was a great celebration when Congress agreed to repeal the flawed SGR formula for adjusting Medicare payment rates. Unfortunately, the voices of those of us who were very concerned about its replacement – MIPS – fell on deaf ears. We are now living with the MIPS mess.

To avoid a nine percent penalty in Medicare payments physicians must comply with the administrative hassle described briefly above. Nobody benefits from this; it has not even improved quality – its avowed intent. Those who attempt to qualify for bonus payments are disappointed since the bonuses are funded by the penalties, and most avoid the penalties by accepting the administrative burden since a nine percent penalty is excessively punitive.

The net result is that we have added a greater administrative burden to a system already overwhelmed with very expensive administrative excesses with the reward being merely avoidance of a monetary penalty, without extra funds being appropriated for potential of paltry rewards.

CMS continues to push this program, presumably based on the fiction that it improves value. If they really wanted greater value in health care, they should look at the $600 billion in recoverable administrative waste that we could free up by enacting and implementing a well designed, single payer, improved Medicare for All. Enough with the MIPS mess.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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