Boosting MIPS Scores Sets the Stage for Increased Revenue

The Medicare Quality Payment Program has officially launched, meaning most physicians (and most non-physician practitioners) are in the initial performance period under the Merit-Based Incentive Payment System (MIPS).  With 60 percent of the MIPS composite score based on quality measures in the first year, the selection of the most appropriate measures, and the manner in which to report, is critical for practices to know.

The Basics

To maximize their quality component scores, physicians - either individually or as part of a group -must report on a minimum of six measures, at least one of which is an outcome measure.  Under the quality portion of MIPS' predecessor, the Physician Quality Reporting System (PQRS), most physicians reported on a small subset of their Medicare patients.  With MIPS' quality section, however, physicians must report on at least 50 percent of their relevant patient population depending on their submission method (i.e., Part B claims, EHR, registry, and CMS web interface).

A physician's quality component score will be calculated by comparing the physician's score on each measure to historical benchmarks.  CMS has calculated those benchmarks based on physicians using the same submission method scored on that measure during prior reporting periods.  In other words, each measure has up to four separate historical benchmarks, one for each reporting submission method.

In late December of last year, CMS released the 2017 quality measure specifications (i.e., numerators and denominators) and benchmarks for all of the nearly 300 MIPS quality measures.  With this information now available, physicians can make informed decisions regarding MIPS quality reporting.

When selecting required quality measures, physicians should:

• Identify measures relevant to their patient populations, starting with CMS' 30 specialty-specific measure sets.  Specialists for whom CMS has not provided a measure set may look to their specialty societies for guidance. 

• Review the measures in which they previously reported for PQRS or other pay-for-reporting programs. 

• Compare their historical scores to the aforementioned benchmarks before deciding to continue with the same measures.  All scores are relative:  a score of 95 percent isn't worth much if 90 percent of physicians scored 96 percent or above. 

• Consider that one quality measure may have up to three different benchmarks, depending on the number of ways in which data may be reported for that measure.  For some measures, data can be reported three different ways (by administrative claims, EHR, or registry), whereas some measures require data be reported in one specified manner (e.g., registry only). 

• Avoid "topped-out" measures – meaning there is little difference between the worst and best performers on the measure.  Once a measure tops out, it is on the short road to retirement, as there is no longer an opportunity for improvement in the performance it measures.  It will be difficult to score well on these measures.

So How to Decide?

The equation for measure selection for purposes of improving one's quality component score requires consideration of several variables.  As stated before, physicians must evaluate different measures' relevance to their practices and the relative ease and reliability of data collection.  A physician or group also must consider the extent to which existing work flows will need modification to improve performance on a specific measure.

With CMS' publication of the 2017 quality measure benchmarks, physicians and groups will need to evaluate the level of performance required to earn a specific number of points toward their quality component scores.  As part of this evaluation, physicians also must decide the manner in which they will report, as all measures must be reported the same way.  For example, if a physician identifies three measures on which he or she wants to report, and those measures require registry reporting, the physician then could not select measures that require another manner of reporting.

Across all MIPS components, physicians have timing and participation flexibility for meeting MIPS requirements in 2017.  CMS considers 2017, the first year of MIPS, a transition year during which physicians can meet lesser requirements for shorter periods of time to avoid any financial penalties.  This performance year remains an excellent opportunity for physicians to attempt to meet full requirements with little downside (time and effort) and realize the potential for significant financial upside (up to +12 percent of base fee-for-service payments in 2019).

Aaron Elias is a consulting senior at PYA (Pershing Yoakley & Associates), a healthcare consulting firm serving clients in all 50 states.  Lori Foley, principal, leads PYA's compliance and business support and improvement services team.  Following a two-decade career as a healthcare and regulatory attorney, Martie Ross, principal, helps providers navigate the ever-expanding maze of healthcare regulations.