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(A huge thanks to Dr. James Kennedy, who co-wrote this newsletter with me.)

Like it or not, the government believes that physicians are responsible for escalation of medical costs in the United States. So when President Bill Clinton signed the Balanced Budget Act of 1997, Congress mandated that Medicare payments for physician services be limited to a “sustainable growth rate” (SGR) determined by a complicated formula with the hope of eliminating the federal deficit by 2012 (Spoiler: It didn’t. Learn more here).

But there was a problem.

Physicians were billing higher than the sustainable growth rate whereby CMS was required to reduce their fees initially by 4.8% in 2002 up to a whopping 26.3% in 2013, requiring the AMA to beg Congress each and every year for exemptions.

Are You Down With the QPP?

As a consequence, the AMA requested that Congress pass the “Medicare Access and CHIP Reauthorization Act” (MACRA) of 2015 to replace the SGR methodology with a “Quality Payment Program” (QPP) intended to prioritize value over volume.

The QPP requires that physicians receiving Medicare funds participate in one of the following tracts (unless meeting certain exclusion criteria)

1. The Merit-Based Incentive Payment System (MIPS)

2. Advanced Alternative Payment Models (APM). Note: This established accountable care organizations (ACOs), which I discussed in a previous newsletter.

Each of these have various incentives and penalties that can range for plus or minus 9% of a physician’s traditional Medicare fees.

If you just had a moment of panic and have no idea which one you’re in, fear not. You can either ask your practice manager or investigate this for yourself at the QPP website using your individual NPI number. After doing so, then ask your practice manager how CMS scored your performance.

If you’ve never heard of MIPS, it’s likely because you belong to an ACO and fall under an APM (like me).👇️ 

For 2025, the Advance Alternative Payment Models are likely to be

• Bundled Payments for Care Improvement Advanced Model

• ACO REACH (formerly Global and Professional Direct Contracting) Model

• Kidney Care Choices Model (Comprehensive Kidney Care Contracting Options,

  Professional Option and Global Option)

• Maryland Total Cost of Care Model (Care Redesign Program; Maryland Primary

  Care Program)

• Medicare Shared Savings Program (Level E of the BASIC Track and the

  ENHANCED Track)

• Enhancing Oncology Model (EOM)

• Primary Care First (PCF) Model

What is MIPS?

If you are not involved with one of these advanced APMs, you will be required to participate in MIPS if you or your group:

• Bill Traditional Medicare more than $90,000/year and

• See more than 200 Medicare Part B patients (read about Medicare parts here) and

• Provide more than 200 covered professional services to Medicare Part B patients.

Since many physicians qualify for MIPS by these criteria, you should recognize its four main aspects

1. Quality - 30 points

2. Promoting Interoperability - 25 points

3. Improvement Activities - 15 points

4. Cost - 30 points

Up to 10 “complex patient bonus” points are granted based on the volume of “dual-eligible” Medicare patients with Medicaid (5 points) and the cost burden of the physicians’ practice based on their CMS hierarchical condition category (HCC) score (5 points).

Physician performance with these metrics produce a score that impacts whether Medicare will increase, decrease, or keep neutral their payments to you (more later).

Quality

Quality is 30% of the Final Score and “assesses the quality of the care you deliver.”

You must report 6 quality measures but you get to pick the quality measure that best fits your practice. You can see the entire list of quality metrics here.

These range from “age-appropriate colon cancer screening” to “acute posterior vitreous detachment and acute vitreous hemorrhage appropriate examination and follow up.” You can see how a PCP might select the former, but an opthamologist would select the latter.

Promoting Interoperability

This is 25% of your final score and essentially assess your use of technology to “exchange and make use of information [that] makes communicating patient information less burdensome and improves outcomes.”

Before we even get to the objectives, you must “use EHR technology certified by the office of the National Coordinator for Health Information Technology (ONC)” that meets the certification criteria in 45 CFR 170.315 and provide your EHR’s CMS identification code from the Certified Health IT Product List.

Is your brain hurting yet?

Ok, now the 4 objectives:

1. Electronic prescribing (e-prescribing)

2. Health information exchange

3. Provider to patient exchange

4. Public health and clinical data exchange

You can see all the requirements for those objectives here.

Improvement Activities

This is 15% of your final score and “assesses how you improve your care processes, enhance patient engagement in care, and increase access to care.” You choose between 1 and 4 activities (depending on your reporting requirements) which are appropriate to your practice. You can see the list here.

Cost

This is 30% of your final score and “assesses the cost of the patient care you provide.” There are 29 cost measures available in 2024 and range from “AKI requiring new inpatient dialysis” to “Total Per Capita Cost.” You can see the entire list here.

Your Final Score and Payment Adjustment

All of this goes into a final score that impacts your payment adjustment which will either be negative, neutral or positive. Essentially, if your score is below 75 points, it will be negative. If it is above 75 points, it will be positive. This can be as much as a -9% reduction of payments for all covered professional services you bill to Medicare. Note that they do not define how much positive adjustment there might be because, there it is again, budget neutrality. Here’s the chart:

If you’re participating in MIPS either individually or in a group, I imagine you have an idea of how you’re doing. If not, you can go here to find your score.

The Elephant in the Room

Did someone say over-regulation?

You can see that although this incentive program is designed to reduce costs and increase value, this adds a great deal of complexity and administrative burden (not to mention the contributions to stress and burnout) and I’ve vastly oversimplified it. Click on any of the CMS / QPP links above and you realize just how complicated these things are with all their exceptions and additional requirements.

Avoiding these requirements is why some clinicians, including some ERs and hospitals, do not accept Medicare patients. Is that good for Medicare patients? Probably not.

I would like to see Congress / Medicare take a step in simplifying all of this. But is the devil you know better than the devil you don’t know? Would simplification of the payment structure result in a reduction in payment to clinicians and hospitals? Time will tell.

That’s all for now. Don’t hesitate to ask questions as they help inspire future issues!

Cheers,

Robert

Again, thanks to Dr. James Kennedy, who co-wrote this newsletter with me. He is a CDI consultant available to assist your facilities when requested. Please reach out to him at [email protected] as you see fit.

Thanks to Laura Samson, RN BSN CCDS, and my wife Kara (for grammar) for editing this newsletter!

When you’re ready, there are 3 ways I can help you:

1. Join our CDI and Coding Village online community! It’s impossible to know it all, it takes a village! What you’ll get:

• Learn from me and other experienced professionals (perfect for new coders / CDI’s and those pivoting their career)

• Participate in monthly interactive webinars hosted by me, weekly 1 minute CDI quick tip videos, and anatomy and physiology reviews not found anywhere else

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• Impress your attendings and improve your evaluations.

• Prepare for real-world productivity pressures

• Gain the confidence to write shorter yet more effective notes.

• Use notes to make you a better, more prepared physician

If you were forwarded this newsletter and would like to subscribe:

Sources

• https://qpp.cms.gov/mips/how-eligibility-is-determined

• https://www.youtube.com/watch?v=WBWAWNfZye4

• https://qpp.cms.gov/mips/traditional-mips

• https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2292/MIPS%20Promoting%20Interoperability%20Performance%20Category%20Fact%20Sheet.pdf

• https://qpp.cms.gov/about/qpp-overview

• https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2510/2024MIPSPaymentAdjustmentGuide.pdf