Unpacking Proposed Merit-Based Incentive Payment System Changes

August 07, 2019 - CMS is planning to overhaul reporting for the Merit-Based Incentive Payment System (MIPS) in order to make the pay-for-performance program less burdensome and more meaningful to providers, according a recently proposed rule.

As reported last week, CMS proposed revisions to the Medicare Physician Fee Schedule and Quality Payment Program for the 2020 calendar year. Chief among the revisions was the MIPS Value Pathways (MVPs), a conceptual participation framework that would streamline MIPS reporting by requiring eligible clinicians to report on a smaller set of measures that are specialty-specific, outcome-based, and more closely aligned with alternative payment models starting in the 2021 performance year.

What are MVPs and how will the transition to a new MIPS reporting structure impact clinician participation in 2020 and beyond? RevCycleIntelligence.com explores proposed changes from CMS, including the MVP methodology and how CMS plans to make the transition.

What are MIPS Value Pathways, or MVPs?

MIPS reporting is a major burden on providers, according to a 2018 survey conducted by the Medical Group Management Association (MGMA). Eighty percent of group practice leaders cited the Quality Payment Program as their top regulatory burden, and another 67 percent said they were specifically dissatisfied with MIPS reporting requirements and methods.

CMS has also received negative MIPS reporting feedback from eligible clinicians. In a fact sheet on proposed MIPS changes in calendar 2020, CMS reported that clinicians said:

• MIPS performance requirements are still confusing
• Too much choice and complexity with choosing and reporting on MIPS measures
• Misalignment among MIPS performance categories
• Demand for better performance comparability across clinicians
• Need for increased emphasis on patient experience

READ MORE: Maximizing MIPS Scores Through Chronic Disease Prevention

The MVP framework would address provider burdens and other concerns by shifting clinicians away from reporting on siloed activities and measures and towards an aligned set of measures that are relevant to the clinician’s scope of practice, CMS explained.

The participation framework would also align and connect measures across the four MIPS performance categories (Quality, Cost, Promoting Interoperability, and Improvement Activities) for specific specialties or conditions.

Specifically, CMS plans to have clinicians report on the same “foundational” measures, which are based on Promoting Interoperability measures and a set of administrative claims-based quality measures that focus on population health and public health priorities.

Then, clinicians would report on measures across the Quality, Cost, and Improvement Activities categories based on their specialty or the condition being treated.

“We believe this combination of administrative claims-based measures and specialty/condition-specific measures would streamline MIPS reporting, reduce complexity and burden, and improve measurement,” CMS stated in the fact sheet.

READ MORE: Exploring Virtual Groups in the Quality Payment Program, MIPS

Another key component of the MVP framework proposal is enhanced data and feedback to clinicians, the agency highlighted. CMS proposed to analyze existing Medicare information to provide timely and better feedback to clinicians on how to improve health outcomes.

CMS plans to shift eligible clinicians to the MVP framework within the next two years. In the meantime, clinicians will face a transitional year in 2020.

What does the new proposal mean for MIPS reporting in 2020?

CMS intends to lay the groundwork for the MVP framework during the 2020 performance year. Therefore, the agency proposed to maintain many of the MIPS reporting requirements from the 2019 performance year, while implementing updates based on clinician feedback and statutory requirements.

Eligible clinicians would still be able to participate in MIPS using the “Pick Your Pace” structure. However, CMS would update the performance thresholds in 2020 to advance the pay-for-performance program. Specifically, the agency plans to:

• Increase the performance threshold, or minimum number of points to avoid a negative payment adjustment, from 30 points in 2019 to 45 points in 2020 and 60 points in 2021
• Increase the additional performance threshold for exceptional performance to 80 points in 2020 and 85 points in 2021

CMS does plan to move forward with full MIPS implementation by the 2022 performance year, which is the sixth year of the Quality Payment Program. At that time, the agency intends to set the performance threshold as the mean or median of the final scores for all MIPS eligible clinicians for the previous period.

READ MORE: The Pros and Cons of Quality Measure Choices In MACRA, MIPS

In terms of MIPS performance categories, CMS proposed to reduce the weight of the Quality performance category to 40 percent in 2020, 35 percent in 2021, and 30 percent in 2022, while increasing the Cost performance category weight to 20 percent in 2020, 25 percent in 2021, and 30 percent in 2022.

CMS has been gradually introducing the Cost performance category under “Pick Your Pace” to give clinicians time to adjust to new cost-based measures. But the performance category is scheduled to weigh as much as the Quality performance category by the 2022 performance year.

The Cost performance category is slated to have ten new episode-based measures in 2020, as well as revised current measures, the proposal rule stated.

For the Improvement Activities performance category, CMS proposed the following changes:

• Change the definition of rural area
• Eliminate the requirement that a practice must have received accreditation from one of four accreditation organizations that are nationally recognized or comparable specialty practice that has received the NCQA Patient-Centered Specialty Recognition to be considered a patient-centered medical home  
• Boost the participation threshold for group reporting from a single clinician to half of the clinicians in the practice
• Update the Improvement Activity inventory and create criteria for removal in the future

CMS did not propose significant changes to the Promoting Interoperability performance category.

Complying with MIPS reporting requirements as stated in the recently proposed rule would give clinicians the opportunity to earn an adjustment of nine percent on their Medicare Part B reimbursement in 2022 based on their 2020 performance.

However, CMS stated in the proposed rule that it anticipates the overall payment adjustment to be 1.4 percent based on the proposed changes.

The proposed MIPS changes are not yet set in stone and industry groups are already busy trying to change course.

AMGA (American Medical Group Association) criticized the proposed MIPS changes, arguing that finalizing the rule would no longer qualify MIPS as a system transitioning providers to value-based care, but rather a regulatory burden.

“We are entering the fourth year of MIPS, and our members expected to have the opportunity to earn a significant payment adjustment if they performed well,” said Jerry Penso, MD, MBA, AMGA president and CEO. “By proposing an overly cautious approach, CMS is not rewarding those organizations that made the necessary investments in and championed value-based care as envisioned by congressional leaders.”

On the other hand, the American Medical Association (AMA) applauded CMS for simplifying MIPS reporting in the proposed rule, saying the agency put forth a “simplified option that would give physicians the choice to focus on episodes of care rather than following the current, more fragmented approach.”

Stakeholders can comment on proposed MIPS reporting changes until September 27, 2019.