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MACRA MIPS and the 2018 Bipartisan Budget Act: Risk, Reward and Reimbursement

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From our partners SpectraMedix

We’re in Q2 of the 2018 MACRA MIPS performance year. CMS confirmed earlier this year that the Merit-based Incentive Payment System (MIPS) is here to stay. Congress underscored this when adopting the 2018 Bipartisan Budget Act, which included MIPS and made changes to make participation less burdensome.

MIPS Background

MIPS updates and consolidates three CMS legacy payment models: Medicare Meaningful Use (MU), Physician Quality Reporting System (PQRS), and the Value‐Based Payment Modifier (VBM). The MIPS program determines performance over 4 categories: Cost, Quality, Advancing Care Information and Improvement Activities. Eligible clinicians (ECs) choose which measures to report for three categories and CMS calculates cost.

Since MIPS is a budget neutral program, low‐scoring clinicians pay high performers. The estimated payment adjustment is set at ±5% for 2018, with adjusted payment in year 2020. That amount may vary based on the number of ECs reporting and their overall composite scores. In order to avoid a negative payment adjustment, clinicians had to score a minimum of 3 points in 2017. For 2018 the minimum score rises to 15 points. High performing clinicians with scores topping out between 70 and 100 points are eligible to share part of an “exceptional bonus pool” of $500M budgeted by CMS.

The MIPS transition year ended on December 31, 2017. Participating clinicians reported late last month and preliminary scores are starting to come in. Final scores and reimbursement rates will be announced in July and Medicare payment adjustment will take place in 2019.

Reporting for SpectraMedix clients has been favorable, with more than 90% of clients achieving a preliminary score of 70 or higher.

2018 Bipartisan Budget Act

Among the changes that ease the transition to a fully value‐based system are actions that slow the overall process. The Budget Act allows CMS more flexibility in applying the cost category weight. Prior to passing the Act, the MIPS cost category weight (out of 100%) was expected to rise from 0% (2017) to 10% (2018)to 30% (2019). The 2018 Act allows the weighted cost score to vary more slowly, but somewhere between 10% and 30% for the next three years.

Medicare Part B drug costs will no longer be a factor in determining clinician eligibility to report. In other words, by removing Part B drug costs, more clinicians will fall under the CMS low‐volume threshold for MIPS reporting. The low‐volume threshold for performance year 2018 excludes clinicians who bill Medicare charges of ≤$90,000 or treat ≤200 Medicare beneficiaries.

The Secretary of Health and Human Services has discretion over when in the next three years the MIPS composite score will level off to either the national mean or median score. At this time the Act does not specify whether the mean or the median will be the benchmark.

Risks and Rewards

Clinicians are able to report individually or by group by Tax Identification Number (TIN). CMS defines a group as 2 or more ECs who have assigned billing to the TIN. All EC scores within a group are aggregated to produce the composite score. If measures are selected that favor one clinician type over another, the composite score may be lowered along with the resulting payment adjustment. All members of the group receive the same payment adjustment.

Whether reporting individually or in a TIN ECs can maximize the opportunity to hit the positive payment or bonus level by attention to measures selection. Additionally, reviewing workflow processes to find areas where improvement is already being achieved can ramp up that category. Pay attention to where CMS offers bonus points, such as treating complex patients and review data to select the most beneficial 90‐day reporting period for Advancing Care Information (ACI) and Improvement Activities (IA).

Reputation is also on the line when reporting for MIPS. Scores will be reported publicly on PhysicianCompare.gov and will be available to download by third parties. Scores can be viewed both by potential patients and potential employers. Hospitals risk patient “leakage” if their employed physicians are low ranking.


CMS and the 2018 Bipartisan Budget Act are easing transition to value‐based payment, but it will happen soon. The transition allows clinicians to remain in MIPS for a longer time period before entering risk-based payment models. The necessary data to prove positive or exceptional performance is available within hospital and group systems but must be extracted, normalized across EHRs and clinician types to be reported effectively.

Find out more about the 2018 MIPS program in a webinar on May 9 at 11 AM, hosted by SpectraMedix, a partner of NJHA Healthcare Business Solutions.

About SpectraMedix

SpectraMedix partners with hospitals, health systems, provider organizations, health information exchanges and payers to improve care delivery and support their transition to value‐based payment models. Our proven eMeasures360™ quality management and eureQa360™ population health intelligence solutions provide advanced data integration, quality measurement and population health analytics capabilities to implement initiatives and programs including the MACRA, Medicaid reform programs, Clinically Integrated Networks, ACOs, financial risk modeling, bundled payments and electronic clinical quality measures.

Nathan Brown, SpectraMedix, Director of Marketing
609‐336‐7733 Ext. 308