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MIPS just grew by 194K providers. Here's what that means for potential incentives.

November 13, 2018

    The Merit Based Incentive Payment System (MIPS) program is about to get bigger. In the recent CMS 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, the definition of eligible clinicians (ECs) for the Quality Payment Program (QPP) was expanded to include new provider types: physical therapists, occupational therapists, qualified speech-language pathologists, qualified audiologists, clinical psychologists, and registered dietitians or nutrition professionals. This, along with additional participation opportunities now available (i.e., an "opt-in" process to MIPS), means more providers can earn MIPS incentives or face penalties—to the tune of about 194,000 more ECs in 2019 compared with the previous year.

    Your guide to the 2019 MACRA Final Rule

    More ECs, more incentives? Not necessarily.

    Many groups may assume that they will earn more incentives when they perform well in MIPS because these newly eligible clinician types will also receive the positive incentive. However, our analysis suggests that assumption is incorrect. It might appear there are more incentives to go around—but, in reality, these incentives are spread thinner than groups might expect.

    To explain, let's recap how incentives and penalties work in the program:
    • MIPS performance translates to a MIPS score from 0 to 100, which then converts to a percentage increase, decrease, or neutral (zero) adjustment that will apply to an EC's future Medicare Part B reimbursement.
    • CMS adjusts the maximum amount it pays "winners" to match the total penalties for those who fall below a certain performance threshold (PT), which how CMS applies the concept of "budget neutrality."
    • There is also $500 million in additional incentive funding set aside for ECs that reach a higher exceptional PT.

    In the below table, we analyzed the CMS estimates to arrive at the year-by-year change to the percentage of ECs that stand to receive penalties, achieve "good" performance (i.e., positive or neutral adjustments), or reach "exceptional'" performance. We have added a column labeled "variance" that shows where the 194K providers fall within the levels of performance (i.e., penalty, good, or exceptional), and we summarized the relative percentage (in red) of those providers in each level.

    This table shows us three things about 2019:

    1. About one-third of new ECs could receive a penalty. You can see that the relative percentage of providers receiving penalties grows from 2.9% to 10.8% year-over-year. The variance column suggests that among the new providers, a higher percentage will receive penalties (i.e., 35%) compared with the overall trend.

    2. More new ECs likely to be "good." Of those newly added providers who will avoid the penalty, the vast majority (i.e., 60%) will not score high enough to earn the exceptional performance incentives.

    3. Large dip in percentage of exceptional performers overall. The majority of ECs will still be exceptional performers, i.e., 57.5% in 2019. However, this is a significant change from 74.4% compared with 2018. This shows that growth of the program to encompass 798,000 total ECs outpaces the number of new providers who can achieve the highest MIPS scores.

    So for the groups that perform well in MIPS, yes; adding new ECs will allow them to also enjoy the incentives earned. But these groups must also out-perform the growing roster of ECs in the program, and meet tougher requirements that CMS finalized for 2019. Join us for a webconference on December 4 as we review all the 2019 QPP program requirements, including how to optimize performance in MIPS.

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