- FAQS ABOUT THE MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS)
What is MIPS?
The Quality Payment Program combines the existing Medicare Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value-Based Modifier (VBM) programs into MIPS, starting with the CY2017 performance year. MIPS payment adjustments are applied to Medicare Part B payments two years after the performance year, with CY2019 being the payment adjustment year for the CY2017 performance year.
A clinician’s annual MIPS score of up to 100 points is determined by four categories of clinician performance and bonus point opportunities. See below for the 2018 performance year, and associated 2020 payment adjustment year:
- Quality (50% weight, or 50 MIPS points maximum)
- Advancing Care Information (ACI) (25% weight, or 25 MIPS points maximum)
- Improvement Activities (IA) (15% weight, or 15 MIPS points maximum)
- Cost (10% weight, or 10 MIPS points maximum)
The final score earned by a clinician for a given performance year then determines MIPS payment adjustments in the second calendar year after the performance year. Each clinician’s annual final score will be released to the public by CMS.
Although MIPS inherits much from the MU, PQRS, and VBM programs, historical high performance or penalty avoidance under the existing programs does not guarantee the same under MIPS. Read on to explore how MIPS specifically impacts performance management and reporting.
What are the financial and reputational impacts of MIPS?
MACRA defines two types of financial impacts for Medicare Part B clinicians participating in MIPS:
- A small, annual inflationary adjustment to the Part B fee schedule
- MIPS value-based payment adjustments (incentives or penalties) based on the MIPS 100-point final score
The Medicare Part B inflationary adjustment is an annual +0.5% increase for the payment years 2016 to 2019, which is the first payment year for MIPS associated with the first performance year (2017). There is no inflationary adjustment from 2020 to 2025. A subsequent annual inflationary adjustment of +0.25% applies to the payment year 2026 and thereafter.
The potential MIPS incentives and penalties driven by the MIPS score are much more substantial than the inflationary adjustments. The following table shows the top-to-bottom Part B payment adjustment impact range in the initial program years:
MIPS Payment Adjustments: Maximum Impact Range
|PERFORMANCE YEAR||MEDICARE PART B
PAYMENT ADJUSTMENT YEAR
MIPS BASE INCENTIVE
(CMS predicts 0.86% )
(CMS predicts 1.52% )
(CMS predicts 0.30% )
(CMS predicts 1.75% )
The maximum penalty increases to 9% of Part B payments for the 2020 performance year. The maximum incentive is the sum of a maximum base incentive and a maximum exceptional performance bonus, which depend on respective scaling factors, X and Y. We explain below how the predictions and estimates shown in the table were derived.
CMS calculates X (the “budget-neutrality factor”) such that the national base incentive pool is set equal to the national penalty dollars assessed. Through this mechanism, those earning incentives are effectively being paid by those receiving penalties for substandard performance. X is capped at 3.0, such that the theoretical maximum incentive for the 2020 performance year would be +9% * 3.0 = 27%. Due to the authority MACRA grants CMS to make it easier to avoid penalties for the initial 2017 and 2018 performance years, CMS predicts relatively low maximum incentives of 2.38% and 2.05%, respectively (references: 2017 and 2018 QPP Final Rules). Additionally, the Bipartisan Budget Act of 2018 extended the transition period through 2021. However, given the MACRA rules for benchmarking MIPS in the 2022 performance year, it is reasonable to expect that X will be approximately 1.0 in that year (the situation where the number of penalized clinicians roughly equals the number clinicians earning incentives), which would yield a ~ 9% maximum base incentive for 2022 performance.
CMS calculates Y by allocating $500M per year (available each year through 2022) to an exceptional performance bonus pool for high performers based on scoring rules described further below. As shown in the table above, CMS predicts Y = 0.175 for the 2018 performance year, yielding a maximum exceptional performance bonus of 1.75%. Furthermore, CMS predicts that 74% of 600,000 MIPS eligible clinicians (444,000 clinicians) will earn an exceptional performance bonus (minimum of 0.5%) for 2018 performance.
What is an Advanced Alternative Payment Model (Advanced APM) and its relationship to MIPS?
Clinicians in entities sufficiently participating in Advanced APMs are exempt from MIPS. In order to understand Advanced APMs, you must first understand how MACRA defines an alternative payment model (APM), of which Advanced APM is a subclass. Strictly speaking, an APM includes only these payment models run by CMS (not by commercial payers):
- CMS Innovation Center Model (other than a Health Care Innovation Award)
- Medicare Shared Savings Program Accountable Care Organizations (MSSP ACOs)
- Demonstration under the Health Care Quality Demonstration Program
- Demonstration required by federal law
There are also other payer Advanced APMs, which can be run by commercial payers and play only a restricted role within the Quality Payment Program. Other than this one exception, the term APM should be understood as only certain Medicare payment models.
The subset of APMs known as Advanced APMs must fulfill these additional requirements:
- Requires participants to use certified EHR technology
- Bases payment on quality measures comparable to those in the MIPS Quality performance category
- Either APM entities must bear more than nominal financial risk for monetary losses or the APM is a Medical Home Model expanded by the CMS Innovation Center
The QPP lists the following CMS programs as Advanced APMs:
- Medicare Shared Savings Program (two-sided models: Tracks 2 and 3)
- Next Generation ACO Model
- Comprehensive ESRD Care (CEC) (large dialysis organization arrangement)
- Comprehensive Primary Care Plus (CPC+)
- Oncology Care Model (OCM) (two-sided risk track available in 2018)
Clinicians in entities sufficiently participating in Advanced APMs will also receive an annual 5% Medicare Part B bonus.
What are the eligibility requirements and exemptions for MIPS?
The eligibility net for MIPS expands over the first several years as follows:
- CY2017 and CY2018 performance years: Physicians (MD/DO and DMD/DDS), Physician Assistants, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists
- CY2019+ performance years: Expanded to physical and occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dietitians/nutritional professionals
Only those eligible clinicians in the categories above who bill for Medicare Part B (otherwise known as the Physician Fee Schedule) or Critical Access Hospital (CAH) Method II payments assigned to the CAH
- Excluded from MIPS payment adjustments: Payments from Medicare Part A, Medicare Advantage Part C, Medicare Part D, FQHC, or Rural Health Clinic facility payments billed under all-inclusive payment methodologies and CAH Method I facility payments
Exemptions from MIPS
For the CY2017 performance year, there are only three exemptions from MIPS for clinicians who otherwise meet the eligibility requirements above:
- Clinicians in their first year of Medicare Part B participation
- Clinicians billing Medicare Part B up to $30,000 in allowed charges or providing care for up to 100 Part B patients in one year
Clinicians in entities sufficiently participating in an Advanced APM for which either:
- The collective Part B payments for services delivered by the Advanced APM entity’s clinicians to patients attributed to the entity is at least 25% of the payments for services delivered by the entity’s clinicians to all patients who could, but may not, be attributable to the entity (“attribution-eligible”)
- The collective number of patients who receive services delivered by the Advanced APM’s clinicians and who are attributed to the Advanced APM is at least 20% of the number of all patients who are attribution-eligible and received services delivered by the Advanced APM’s clinicians
Note that clinicians may choose to either be rated on an individual-clinician basis or as a group of clinicians billing through a common tax ID. Hence, the preceding references to “clinician” in this eligibility section also hold true if “clinician” is replaced with a “group of clinicians billing through a common tax ID.”
MIPS APM Clinicians
Confusingly but perhaps inevitably, there are clinicians who not only belong to an Advanced APM or a non-Advanced APM, but are also subject to MIPS. For example, Advanced APM clinicians not meeting either minimum thresholds as noted in the bullet points above are also subject to MIPS. The QPP defines special scoring and data submission rules governing a subclass of such clinicians who are called MIPS APM clinicians. A common example consists of clinicians who participate in a one-sided Track 1 Medicare Shared Savings Program ACO, which is a non-Advanced APM but for which MACRA provides provisions to ease MIPS reporting burdens and grant MIPS points for APM participation. For more on the special MIPS rules governing clinicians subject to both QPP tracks and meeting certain additional requirements to be deemed MIPS APM clinicians
What are the MIPS performance categories and how are they scored?
As described above, there are four categories of MIPS eligible clinician performance contributing to a composite performance score of up to 100 points. For the CY2017 performance year (and associated CY2019 payment year), the relative category weightings are:
- Quality (60% for 2017)
- Advancing Care Information (ACI, renamed from Meaningful Use) (25% for 2017)
- Improvement Activities (IA) (15% for 2017)
- Cost (0% for 2017, but will be weighted for 2018 and beyond)
The relative weightings between the Quality and Cost categories change in subsequent years of the program. For the CY2019 performance year and beyond, each of these categories have 30% weightings. In addition, under certain allowable circumstances where clinician performance is unable to be determined for a given category or special rules apply, then MIPS sets that category’s weight to 0% and redistributes the weight to other categories as the MACRA rule specifies. In 2017, at least two categories must be rated for performance in order for the clinician to receive a final score. If a final score cannot be determined, then the clinician receives zero payment adjustment.
MIPS clinicians can choose to be rated on either an individual-clinician basis or as a group of clinicians (defined by a tax ID), with the constraint that the choice applies across all performance categories. A clinician’s achievable final score could be significantly impacted depending upon whether that clinician is rated individually or inherits the final score earned by an entire group. MIPS clinicians also participating in certain alternative payment models, such as Medicare Shared Savings Program ACOs, must be rated as a group of clinicians and do not have the choice to be rated as individuals for certain performance categories.
Each performance category is scored separately as a percentage of maximum possible performance within that category. Then the category-level scores are weighted as listed in the bulleted list above (for 2017) and then summed to produce the MIPS final score.
An important fact is that clinicians who have historically performed well under MU and avoided PQRS and VBM penalties may not yet have high enough MIPS ACI or Quality measure performance to avoid penalties in the long run. MIPS forces historically high performers to re-evaluate their performance status based on how the MIPS scoring system differs from those of MU, PQRS and VBM.
MIPS essentially adopts the quality measures and reporting methods from the PQRS and VBM programs. Although there are some changes to the PQRS reporting methods as described later, for the most part, the quality reporting methods remain the same.
Most clinicians must report up to six PQRS measures, across any combination of quality domains, where one measure is an outcome measure (or a high priority measure, if an outcome measure is unavailable). Groups using Web Interface must report 11 quality measures.
In addition to the six PQRS measures, CMS calculates one population measure for groups with 16 or more clinicians and a minimum of 200 cases. Groups below that threshold will not have a population measure included.
Each measure is assigned a possible 10 quality points so a total of 60-70 quality points are available, respectively, depending on the number of clinicians in the group being rated for MIPS. Each measure earns up to 10 points based upon the percentile-basis performance of that measure relative to national peer benchmarks.
For example, if a PQRS measure has a 62% measure performance rate that is better than 60% of peers reflected in the benchmark, then that measure would earn 7 out of 10 possible points, according to this illustrative measure benchmark table from the MACRA Final Rule:
Example of Using Benchmarks for a Single Measure to Assign Points
|Decile||Sample Quality Measure Benchmarks||Possible Points|
|Decile 1||0 - 6.9%||1.0 - 1.9|
|Decile 2||7.0 - 15.9%||2.0 - 2.9|
|Decile 3||16.0 - 22.9%||3.0 - 3.9|
|Decile 4||23.0 - 35.9%||4.0 - 4.9|
|Decile 5||36.0 - 40.9%||5.0 - 5.9|
|Decile 6||41.0 - 61.9%||6.0 - 6.9|
|Decile 7||62.0 - 68.9%||7.0 - 7.9|
|Decile 8||69.0 - 78.9%||8.0 - 8.9|
|Decile 9||79.0 - 84.9%||9.0 - 9.9|
|Decile 10||85.0 - 100%||10|
Note that tenths of points are possible. If a measure rate lies within a benchmark decile rather than on a decile boundary, then one would linearly interpolate the quality point value between the decile boundaries to derive the quality points to the nearest tenth of a point.
As an example, if all six measures earned seven points each, then the total points would be 6 x 7 = 42 out of a possible 60 points, or 42/60=70%. As the Quality category for the CY2017 performance year has a weight of 60%, then a quality score of 70% would result in the Quality category contributing 70% x 60% x 100 = 42 MIPS points to the clinician’s overall MIPS final score.
MIPS also provides additional paths to achieve a Quality score of 100% by granting bonus points for certain quality reporting activities. So if two bonus points were earned in the example immediately above, then the quality score would increase to (42+2)/60 = 73.3%, resulting in 44 MIPS points. Note that the bonus points are not counted in the Quality score denominator (we still divide by the 60-70 possible points from the 6-7 measures, not by 62 or 72 points), so it is possible to get a Quality score of greater than 100%, in which case the quality score is truncated back down to 100%.
Bonus points may be accrued as follows:
- Up to 10% for submitting high priority measures: Organizations that include high priority measures in the measures they choose to submit can receive a bonus of 1-2 points per measure total up to 10% of the total denominator of the Quality score, e.g. 10% of 60 = 6 max bonus points in the example above.
- Up to 10% for end-to-end electronic reporting: CMS is using the QPP to drive electronic reporting forward. Organizations that use end-to-end electronic reporting can achieve a bonus of 1 point for each measure totaling up to 10% of the possible performance points in the Quality category. Note that this bonus cap is a separate bonus cap from the high priority measures.
For the GPRO Web Interface quality reporting method where a greater number of preselected measures are used, the denominator of the quality score would be the number of measures x 10.
CMS will award:
- Two bonus points for each additional outcome measure reported beyond the required one
- Two bonus points for each patient experience measure reported
- One bonus point for each appropriate use, efficiency, patient safety, or care coordination measure
Advancing Care Information (ACI)
MIPS changes Meaningful Use (renamed to ACI) from an all-or-nothing compliance program to a continuous scoring system where MU measure rates are compared to benchmarks in much the same way as described for the MIPS Quality category immediately above.
For example, if a clinician in the existing MU program achieves a performance rate of 15% on an MU measure with a compliance threshold of 10%, then that clinician is just as compliant with MU as another who achieves a 90% rate on the same measure. However, under the ACI scoring system, the former will only earn 2 out of 10 performance points, whereas the latter will earn 10 out of 10 points, according to the decile measure scoring scale. This explains why a historically high MU achiever may end up having a low ACI score if MU performance rates do not improve.
The ACI category defines 131 ACI performance points that can be earned:
- Base Score: 50 points for reporting either a non-zero numerator or a “yes,” as applies, for selected measures from the MU Modified Stage 2 or MU Stage 3 measure sets
- Performance Score: Up to 90 points for performance on eight measures per the decile scoring scale described above
- Bonus Points: Up to 15 bonus points for reporting to an additional public health registry and aligning with IA
The ACI percentage score is calculated by dividing the number of ACI points by 100 and capping the percentage at 100%, should more than 100 ACI points be earned. If fewer than 100 ACI points are earned, then the ACI performance decreases proportionally. For example, 50 ACI points equates to 50% ACI performance, resulting in 50% (ACI performance) x 25% (ACI category weight) x 100 = 12.5 CPS points contributed by ACI.
Improvement Activities (IA)
Under MIPS, clinicians need to either earn 20 points or 40 points, depending on their size and location.
- MIPS eligible clinicians or groups that are small practices (15 or less clinicians), practices located in rural areas or geographic HPSAs, or non-patient facing need to earn 20 points to get full credit in the IA category.
- All other MIPS-eligible clinicians need to earn 40 points to get full credit in the IA category.
To earn points, clinicians can:
- Report any combination of medium-weight (worth 10 points each) and/or high-weight (worth 20 points each) activities, or
- If a clinician participates in certain APMs, such as the Shared Savings Program Track 1 or the Oncology Care Model, the clinician earns 40 points (all future APMs under the APM scoring model will be assigned at least half credit), or
- If a clinician is in other APMs, the clinician automatically earns half credit and may report additional activities to increase the score
The IA percentage score is calculated by dividing the total IA points by 20 or 40, respectively. Using a general MIPS clinician as an example, 30 points would yield a 30/40 = 75% IA performance score, which in turn would deliver 75% x (15% IA category weighting) x 100 = 11.3 MIPS points.
In 2017, the Resource Use weighting has been set to zero, but in 2018, that increases to 10%. MIPS rates clinicians for Resource Use (Medicare costs of attributed patients) based on 40+ cost measures to account for differences among specialties. There are no separate reporting requirements for clinicians, as the measures are calculated based on claims collected by CMS.
Example of Calculating a Final Score
Assuming that the numerical examples used for the four categories as described above all apply to the same clinician, we can calculate a total MIPS score from the components:
- Quality = (42 of 60 points) x 60% weight x 100 = 42 points
- ACI = (50 of 100 points) x 25% weight x 100 = 12.5 points
- IA = (30 of 40 points) x 15% weight x 100 = 11.3 points (rounded up from 11.25)
- Cost = (14 of 20 points) x 0% weight x 100 = 0 points
- Total MIPS points = 42 + 12.5 + 11.3 + 0 = 65.8
How does MIPS impact Meaningful Use?
First, MIPS does not impact the Medicaid Meaningful Use (MU) nor eligible hospital MU programs. In other words, for these programs, the MU Modified Stage 2 and Stage 3 measures and associated incentives and payment adjustments are not affected by MIPS nor the broader MACRA legislation.
MIPS impacts clinicians eligible for Medicare MU in the following ways:
- Sunsets Medicare Part B payment adjustments and replaces them with MIPS payment adjustments where 25% of the MIPS Composite Performance Score is determined by the Advancing Care Information performance category, which is based upon MU Modified Stage 2 measures (for 2014 Edition CEHRT) and MU Stage 3 measures (for 2015 Edition CEHRT).
- Moves away from all-or-nothing MU compliance based on measure thresholds to a hybrid scoring system for ACI where clinicians earn an all-or-nothing base score for reporting required measures, a continuous performance score for measure rate performance relative to a decile scale and a 5% bonus for reporting to more than one public health registry
- Removes all measure exclusions defined under the MU program, as the hybrid scoring system for ACI is deemed to serve the same goal of providing clinicians flexibility in how to achieve high performance
- Removes the requirement to report electronic clinical quality measures, as quality reporting is already addressed by the MIPS Quality category
- Enables ACI to be reported either for individual clinicians or for a group of clinicians and through additional data submission methods beyond attestation, such as registry and EHR methods, previously reserved only for PQRS reporting
- Requires that clinicians agree to cooperate with surveillance of CEHRT by ONC and to implement CEHRT in good faith such that no inhibition of health information exchange nor information blocking occurs
Note that some MIPS-eligible clinicians such as physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and hospital-based clinicians who were previously ineligible for MU will not be accountable for the ACI category so long as there are not sufficient ACI measures applicable to them. For such clinicians, the ACI weighting towards the MIPS CPS will be set to zero and redistributed to other MIPS performance categories.
Note that providers who have traditionally done well under all-or-nothing MU may not have good ACI scores.
How does MIPS impact PQRS and the Value-Based Modifier?
MACRA sunsets the standalone Physician Quality Reporting System (PQRS) and Value-Based Modifier (VBM) programs for applying Medicare Part B payment adjustments related to PQRS quality reporting and VBM quality and cost performance. However, the MIPS Quality performance category inherits aspects of the PQRS quality measures and reporting infrastructure created by the PQRS program and leveraged by the VBM quality measurement system as well. For example, the array of PQRS reporting methods, including registry, EHR, and web interface, are largely preserved for the purpose of reporting quality performance under MIPS. In addition, the MIPS Resource Use performance category largely mirrors the VBM resource use measurement system in terms of measures, patient attribution methodology and benchmarking.
On the other hand, there are some significant changes to how quality is reported and rated under MIPS versus the existing programs. The MIPS Quality performance category deviates from PQRS and the VBM quality measurement systems in the following ways:
- For the registry, EHR, and qualified clinical data registry (QCDR) reporting methods currently requiring nine measures and three quality domains, the minimum quality reporting requirement is reduced to only six measures and can span any combination of quality domains; however, the six measures must include one outcome measure.
- A clinician may select six measures from a list of pre-defined “specialty measure sets” culled from the list of individual measures. Should a specialty measure set contain fewer than six measures, then a clinician could meet the minimum reporting requirement by reporting all the measures in the measure set.
- MIPS broadens and revamps the Measure-Applicability Validation (MAV) process, which allows another means for clinicians to report fewer than the required six measures for the registry, EHR, and QCDR reporting methods.
- For the registry and QCDR reporting methods, the “data completeness” standard, which defines the minimum subset of patients within a measure denominator that must be reported, is 50% of Medicare patients for 2017 and increases to 60% in 2018.
- Clinicians intending to use the group practice reporting option (GPRO) (for clinicians choosing to be measured for MIPS performance as a group of clinicians) will only need to declare their specific reporting method by June 30th of the performance year if they choose the CMS Web Interface reporting method and/or choose to report patient experience measures via the CAHPS for MIPS survey (same as the current “CAHPS for PQRS”).
- The PQRS registry measures group method (requiring reporting a minimum of 20 patients per measure) has been eliminated by the Quality Payment Program.
The data submission deadline for all reporting methods, except possibly the GPRO Web Interface method, is March 31st of the year after the performance year.
Quality Performance Scoring and Benchmarking
Each measure earns quality points based on a percentile scale versus benchmarks, e.g. a 55% measure rate may be greater than that of 60% of all clinicians, so the measure earns 7 out of a possible 10 points.
In order to derive the MIPS Quality points contributing to the clinician’s MIPS final score, add up the quality points across reported measures, divide by the maximum possible points to derive a quality score as a percentage, then multiply this quality score by 60 (for CY2017). The MACRA final rule contains some illustrative examples:
- Bonus quality points are available for specific high-priority measures and for using CEHRT to report measures electronically end-to-end (note that a quality score > 100% due to bonus points still only yields a maximum 60-point quality contribution to the MIPS final score).
- Each reporting method will have a different set of measure benchmarks for the measures reported through that method. The baseline period for deriving benchmarks will be two years prior to the performance year, which increases the likelihood that CMS will publish measure benchmarks prior to the start of the relevant performance year.
- The VBM feedback report, or “QRUR,” will be replaced by a MIPS feedback report for clinicians to see how they scored for the performance year, but the report will likely still be delivered ~9 months after the performance year ends.
Essentially, the significant changes introduced by MIPS to how clinician quality performance is calculated and reported will force many clinicians to revise how they select PQRS reporting methods and measures, as well as how they monitor and predict quality performance.
Note that providers who have traditionally avoided PQRS/VBM penalties may not have a high enough MIPS Quality score to avoid MIPS penalties.
What are MIPS data submission requirements?
The Quality Payment Program intends to move clinicians towards using a single data submission method for multiple performance categories of MIPS. To support this, MIPS expands existing PQRS quality reporting methods, such as registry, EHR, and QCDR, to allow for reporting measures across the MIPS categories of Quality, ACI and IA. The Cost category is claims-based and thereby does not require clinicians to separately report cost information.
MIPS APM Clinicians
For a MIPS eligible clinician also participating in an APM and meeting certain additional requirements (a MIPS APM clinician), For example, for a MIPS APM clinician, the MIPS Quality category may not require a separate data submission if the APM is already collecting quality data for CMS to analyze.
What is 2018 PI Transition Measure Security Risk Analysis?
Eligible clinicians must attest YES to conducting or reviewing a security risk analysis and implementing security updates as necessary and correcting identified security deficiencies.
The Office of the National Coordinator for Health Information Technology (ONC) and the HHS Office for Civil Rights (OCR) have jointly launched a HIPAA SECURITY RISK ASSESSMENT (SRA) TOOL . The tool’s features make it useful in assisting small and medium-sized health care practices and business associates in complying with the health insurance portability and accountability act (HIPPA) security rule. The SRA tool also produces a report that can be useful for audits.
Since your practice is unique and you know your practice best, you are ultimately responsible for adopting and implementing security and privacy measures that are appropriate and reasonable for your practice's needs and capabilities.
For additional support, you should consult with a qualified professional who can use his or her expertise to help mitigate potential risks, identify potential areas for improving security, and train your staff. CMS has also created a SECURITY RISK ANALYSIS TIP SHEET to help you understand this requirement.
Make sure to keep any documentation you use for your records to prove you have completed this measure during your reporting year: It is acceptable for the security risk analysis to be conducted outside the selected MIPS performance period, however, the analysis must be unique for each MIPS performance period, the scope must include the full MIPS performance period, and the analysis must be conducted within the calendar year of the MIPS performance period (January 1st – December 31st).