January 7, 2020 Advisory Board's take: What this data means for providers

More clinicians participated in MACRA's Advanced Alternative Payment Model (Advanced APM) track and Merit-based Incentive Payment System (MIPS) in 2018, and more participating clinicians will receive positive payment adjustments, CMS Administrator Seema Verma wrote Monday in a blog post.


Under MACRA's Quality Payment Program (QPP), which took effect in 2017, eligible clinicians can choose from two payment tracks:

  • The Advanced APM track, for clinicians who take on a significant portfolio of Advanced APMs, which include risk-based accountable care organization (ACO) models; or
  • MIPS, for providers who are reimbursed largely through fee-for-service.

Clinicians' pay in the MIPS track largely follows a traditional fee-for-service structure, but CMS adjusts eligible clinicians' pay based on how they "score" in four categories of metrics:

  • Cost;
  • Improvement activities;
  • Promoting interoperability, formerly called Advancing care information (ACI); and
  • Quality.

But for the 2020 payment year, which is based on 2018 data, eligible clinicians needed to report on a full year's worth of quality data, and CMS increased the performance threshold to 15 points for providers to avoid the 5% penalty, applied to payments in 2020. Beginning in the 2021 performance period, the new MIPS Value Pathways (MVP) participation framework will seek to overhaul MIPS reporting to reduce burden and make the program more meaningful for participating clinicians and patients.

Clinician participation rises in 2018, Verma says

In Monday's blog post, Verma wrote that 2018's participation rates for MIPS and Advances APMs exceeded 2017's participation rates. For example, Verma wrote Advanced APM participation in 2018 increased as more clinicians earned Qualifying APM Participant (QP) status. Verma wrote 183,306 eligible clinicians earned QP status in 2018—up from 99,076 eligible clinicians in 2017.

CMS in July said MIPS participation via APMs increased from 341,220 participants in 2017 to 356,828 in 2018, while MIPS participation without an APM decreased from 1,057,824 participants in 2017 to 916,058 participants in 2018.

More clinicians receive positive payment adjustments, Verma says

Verma also wrote more clinicians are expected to receive a positive payment adjustment in 2020 based on their performance in 2018. Overall, Verma wrote the "national mean (or average) and median scores increased from 2017."

According to Verma, 98% of eligible clinicians participating in MIPS will receive a positive payment adjustment in 2020 based on their 2018 performance.

Verma noted 97% of eligible clinicians in rural practices will receive a positive payment adjustment—up from 93% for the 2017 performance year. Verma wrote 84% of eligible clinicians in small practices also will receive a positive payment adjustment in 2020 for their 2018 performance, an increase from 74% in 2017.

In addition, Verma wrote 872,148 MIPS-eligible clinicians will receive a neutral or positive payment adjustment in 2020 based on their individual, group, or Alternative APM participation in 2018. According to Verma, "Clinicians who specifically participated in MIPS through an APM had a mean score of 98.77 and a median score of 100."

However, Verma wrote, "Positive payment adjustment will remain modest in part because, under the MACRA law, the positive and negative payment adjustments must be budget neutral."

According to CMS, positive payment adjustments will range from 0% to 0.20% for 13% of MIPS-eligible clinicians, with another 84% of MIPS-eligible clinicians receiving an additional adjustment for exceptional performance for a total incentive ranging from 0.21% to 1.68%. CMS data show negative payment adjustments, which will affect about 2% of MIPS-eligible clinicians, will range from -0.01% to -5%.

Verma added, "Although the results are encouraging, there are clinicians who will receive negative payment adjustments. We are committed to supporting these clinicians to reduce reporting complexity and burden, encourage meaningful participation, and improve patient outcomes" (LaPointe, RevCycleIntelligence, 1/6; Verma blog post, 1/6).

Advisory Board's take

What this data means for providers

Ye Hoffman, Senior Consultant, Quality Reporting Roundtable and Julia Connell, Senior Analyst, Quality Reporting Roundtable

Overall, the final 2018 MIPS data further confirmed that the distribution of MIPS scores among providers is overwhelmingly high. A closer look at the numbers shows that:

  • Performance skews heavily toward high scores. The national average was 86.96 points. Even more striking was the median score, 99.63 points. That’s barely below a perfect 100-point score, and reflects an extremely high midpoint in the score distribution;

  • Almost everyone was a "winner." A whopping 84% of MIPS providers scored at or above the 70-point exceptional performance threshold. On the other end of the spectrum, a relatively low MIPS performance threshold of 15 points resulted in few providers receiving penalties, only about 2% to be exact;

  • But the incentives are low. Providers who achieved the maximum MIPS score in 2018 will receive a 1.68% positive adjustment in 2020. That already includes the additional $500 million Congress set aside to fund incentives for exceptional performance.

As we begin a new year, let's not let the 2018 findings distract us from keeping up with evolving program requirements this year. Providers must maintain forward momentum to avoid penalties and earn potential incentives. Here are our recommendations:

  • Report 2019 MIPS data now through March 31st. Providers have until March 31, 2019 to submit their MIPS data to CMS. To confirm your best MIPS reporting strategy, see our webinar on the 2019 QPP requirements;

  • Rise to meet the growing MIPS challenge. In 2020, MIPS penalties reach -9% and threshold to avoid penalties rises to 45 points. The threshold for exceptional performance bonus rises to 85 points. As MIPS gets more difficult, we encourage providers to think longer term—the good news is that excellent MIPS performance prepares groups for participation in alternative payment models;

  • Move toward risk-based contracts. The number of APM track participants nearly doubled in 2018. To qualify for the APM track and earn a 5% bonus, practices should carefully consider their Medicare risk strategy and readiness to take on risk-based contracts. CMS continues to create additional opportunities for providers to enter into Advanced APMs, with models that are applicable to primary care and specialty care providers; and

  • Get ready for even more significant MIPS changes ahead. CMS introduced a new framework, MIPS Value Pathways (MVPs), which is set to begin in 2021. The goal is to bundle measures across categories based on specialty or medical condition. But many details remain unclear and CMS is seeking feedback from stakeholders on how MVPs should be implemented. As always, we will be closely monitoring CMS rulemaking this year to update you on any new details.

To learn more about how your organization can succeed in MACRA in 2020 and beyond, make sure to check out our on-demand webinar, the 2020 MACRA final rule detailed analysis.

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