April 3, 2017

The Medicare Access & Chip Reauthorization Act of 2015 (MACRA) marked the end of Medicare payment’s fee-for-service model and the beginning of a performance-based payment system, the Quality Payment Program (QPP).  Understanding how participation in the QPP will impact your payments begins with understanding the scoring system.

Scoring in the QPP is impacted by the eligible clinician’s (ECs) choice of one of two tracks: the Advanced Alternative Payment Models (APMs) or the Merit-Based Incentive Payment System (MIPS).  As noted in one of our previous MACRA eAlerts, most ABC clients will participate in MIPS in the 2017 transition year.

This eAlert explains the scoring system for MIPS from a high level, including the following:

• The scoring system’s performance thresholds, laying out the points needed for positive payment adjustments
• The categories in which clinicians can score points, including an explanation of the benchmark scoring for Quality that is 60% of the clinician’s score
• Suggestions for how to plan your MIPS strategy within CMS’s new “pay for performance” model

MIPS’ scoring system is on a scale of 0-100.  The score will impact how the Centers for Medicare and Medicaid Services (CMS) calculates payments, trailing two years. A good score in 2017 means a positive payment adjustment in 2019, and so on.  The MIPS score will be used to calculate payment adjustments on a sliding scale from a 4% positive or 4% negative payment adjustment based on 2017 scores (paid in 2019) ramped up to +/- 9% scored in 2020 and paid in 2022.  Payment adjustments will be on a linear scale, so every point earned will mean a larger reimbursement.

Four Scoring Thresholds

The MIPS scoring system has four distinct thresholds.  As 2017 is the transition year for clinicians to join the new program, CMS has tried to make the scoring system as friendly as possible to those just beginning to participate in MIPS.  Not participating at all means a score of zero points, but even modest participation will translate to a score above the positive payment threshold of three points, thereby reaching the neutral payment adjustment.

• 0 Points: Clinicians who do not participate in MIPS at all will receive zero points and a negative 4% payment adjustment.
• 3 Points: Even modest participation in MIPS, commonly called the “test pace” option, will earn three points and qualify for a neutral payment adjustment (neither a positive nor negative change in payment).
• 4–69 Points: This is the range where clinicians can begin to see modest payment adjustments.  Positive payment adjustments will be assigned on a linear sliding scale, with higher scores bringing clinicians closer to the maximum 4% positive payment adjustment.
• 70–100 points: This group is eligible for the exceptional performance bonus, which will use additional funds to boost positive payment adjustments for top performers.

These thresholds will change in subsequent years, but during the 2017 transition year, the QPP provides a large range of positive payment adjustments for enrollees who earn between 4 and 100 points.

The sliding scale for payment adjustments will depend on several factors, ranging from the available money retained in negative payment adjustments to the scores of participating clinicians.  CMS will take scores in the 4-100 range and apply an adjustment factor that takes these factors into account. For those scoring in the exceptional performance range of 70-100 points, additional funds are available for a minimum 0.5% performance bonus, possibly scaling as high as a 10% bonus.

Four Performance Categories

In order to earn points, ECs can choose to participate in MIPS' four performance categories: Quality, Improvement Activities, Advancing Care Information and Cost.  The amount that each category contributes to the MIPS final score will change over time, but in 2017, Quality comprises 60% of the MIPS score, Improvement Activities 15%, Advancing Care Information 25% and Cost 0% (to ease the transition to MIPS).  The methods to earn points in each category are unique:

• Quality (60%): the Quality category is scored by reporting on six quality measures for the full reporting period.  For at least half of the episodes in the reporting period, ECs need to record their performance. (In future years, this reporting rate will increase.) Those of you who have participated in past CMS programs will recognize this as the successor to the Physician Quality Reporting System (PQRS).
• Improvement Activities (15%): Reporting Improvement Activities requires selecting activities from CMS’s list, which contains over 90 options.  Each activity is either a high or medium "weight," and ECs will need to attest to CMS some combination of four mediums, two highs or a high and two mediums.  Some groups can earn double points, reducing the number of activities they need to attest to for full credit.
• Advancing Care Information (ACI) (25%): To participate in this category, ECs or groups must complete four or five base requirements with a 2014 or 2015 Certified Electronic Health Record (EHR), respectively.  ECs may then score additional performance and bonus points.  ACI’s component measures will be familiar to those who have participated in the Meaningful Use or EHR incentive programs, but ACI's modular scoring and greater flexibility are different from those programs.
• Cost (0%): The Cost category measures resource use, and is the only category that does not require ECs to report anything.  In 2017, CMS will calculate Cost scores from submitted claims. CMS will give ECs feedback through the Quality and Resource Use Reports (QRURs), which were previously used as individualized feedback for the Value Based Modifier.

CMS intends to adjust the score weights and nature of these categories every year to adapt to providers’ changing performance.  In 2017, the transition year, CMS has tried to make scoring points as achievable as possible by weighting the categories toward familiar activities (such as quality reporting). CMS has also tried to provide accommodations for non-patient facing and hospital-based providers and providers in rural or small settings.  Finally, for 2017 only, providers only need to participate for 90 days to be eligible to score in the 4-100 point range.  Earning a positive payment adjustment for 2019 is achievable, with the right registry, EHR and management approach and as long as you are registered and begin collecting data by October 1, 2017.

Most category scoring has a direct relationship between a provider or group's performance and the score earned.  For instance, Improvement Activity scoring is based on a simple attestation: if you perform the activity, you have earned the points.  However, the Cost category (in future years) and the Quality category both have competitive or relative scoring methods.  In 2017, the Quality category's performance scoring method is important to fully understand, since Quality makes up fully 60% of the final MIPS score.  The category's performance scoring system is based on benchmarks derived from previous years' performance data.

In the Quality category, the scale for scoring points varies by measure because each measure has its own benchmark.  An individual quality measure has a scoring potential of 0-10 points.  To assign points, CMS looks at historical performance on that quality measure to establish benchmarks.  The top 10% of a benchmark will earn 9-10 points, the next 10% will earn 8-9 points and so on.  This decile scoring system means that it is possible to perform 95% on a quality measure, but if that is only "average" for the measure (the middle 50% of people reporting that measure had 95% performance), then CMS will award only five points for a 95% score.  Think of this as the equivalent of "grading on a curve."  For measures with very high historical performance, performance rates are so high that only perfect performance can earn the full points, and even 99% performance may only equate to four or five points (CMS refers to these as "topped out" measures).

Optimize Your Scoring Potential

While the Quality category has high standards for benchmarked measures, nearly half of all quality measures do not have benchmarks.  For quality measures without a benchmark, CMS has established a "floor" of three points (out of 10) for measure scores.  This means that, in 2017, it is possible that anesthesia providers selecting measures applicable to their practice may have no applicable measures with benchmarks.  If no submitted measures have benchmarks, a provider's Quality category score will be 18 out 60 points.  CMS will be working to benchmark measures for future years, but in this transition year, many quality measures will only have a three point (out of 10) scoring potential.  To review this year's benchmarks, visit the QPP site's Education page to download the Quality Benchmarks.

QPP Education Page: https://qpp.cms.gov/resources/education  
Quality Benchmarks: https://qpp.cms.gov/docs/QPP_Quality_Benchmarks_Overview.zip

Anesthesia providers wishing to maximize their Quality performance score have some options to increase their Quality category scoring potential.  First, they should work with a specialty registry to help select measures applicable to their practice and take care to consider measures with benchmarks (there are some anesthesia-specific measures with benchmarks).  Secondly, providers should consider submitting as many outcome and patient experience measures as possible.  There are many outcome measures in anesthesia, and each measure submitted past the first required measure is worth two bonus points.  Although capped at 10%, ECs can even submit additional measures past the required six measures to earn the bonus points for supporting high priority measures.

The Quality category reveals CMS's general MIPS strategy.  The MIPS scoring system is designed to reward ECs who are deliberate in strategizing about how to improve patient care over time.  Providers who seek high priority measures focused on patient outcomes and experience will earn higher scores. By incentivizing these activities, CMS hopes to help providers improve their care.

For the overall MIPS score, CMS has set the performance threshold at only three points for the QPP’s transition year.  They will raise the minimum next year (increasing the number of ECs who will receive a negative payment).  In subsequent years—2019 and beyond—the performance threshold will be the mean or median score, as required by MACRA.  Ultimately, a higher minimum performance threshold will mean larger rewards for good performance and deeper negative payment adjustments in the coming years.  The best way to prepare is to start participating now, and to develop a meaningful strategy to ensure the highest quality care.

Questions?  Contact info@anesthesiallc.com or the MACRA MadeEasy hotline at (517) 962-7301.

With best wishes,

Tony Mira
President and CEO