Under MACRA (Medicare Access and CHIP Reauthorization Act),
clinicians can participate in either two payment models, a Merit-based
Incentive Payment System (MIPS), or an Advanced Alternative Payment Model
(AAPM), defined as Quality Payment Program (QPP).
In QPP MIPS, eligible physicians are required to submit
yearly data to CMS to receive a total score. There are four performance
categories, Quality, Improvement Activities (IA), Promoting Interoperability
(PI), and Cost, for which data is recorded and analyzed.
Today, we are discussing the Cost category and its
reporting.
Let’s keep going.
Cost Performance Category
The cost category weighs 15% of the total MIPS score for the
performance year 2020.
Reporting Requirements
CMS doesn’t expect any data submission for the cost
category. They analyze the performance by reviewing claims data.
The following factors impact the analysis of this performance.
- Medicare Spending per Beneficiary (MSPB)
- Total per Capita Cost
- Eight episode-based cost measures
Medicare Spending per Beneficiary (MSPB)
The MSPB assessment refers to the Medicare Part A and B
costs generally incurred in an episode.
An episode includes the dates falling between three days
prior to an Inpatient Prospective Payment System (IPPS) hospital admission (an
index admission) and 30 days post-hospital discharge. It measures the actual
cost of episodes as per their expected expenditure.
To score for this measure, physicians or MIPS Qualified Registry on their behalf need to consider the following aspects.
Physicians, who don’t treat in-house patients don’t qualify
for an episode, and no points will be awarded.
Episodes will be attributed to those clinicians, who provide
the plurality of Medicare Part B services to a beneficiary during the index
admission.
Physicians must report at least 35 cases to get a score for
this category.
Total per Capita Cost
The total per capita cast measure analyzes all Medicare Part
A and B costs for each attributed beneficiary.
However, the following factors are to be considered for maximum points
in MIPS.
Clinicians are supposed to be attributed to at least 20
beneficiaries.
Attribution refers to:
A beneficiary refers to a tax identification number-national
provider identifier (TIN-NPI), provided if the beneficiary (patient) received
primary healthcare services from primary care physicians, nurse practitioners,
physician assistants, or clinical nurse specialists under the same TIN.
If the beneficiary doesn’t qualify as per the
above-mentioned requirement, he/she will be attributed to the TIN-NPI, if they
received services from specialist physicians within a TIN than from physicians
in any other TIN.
New episode-based cost measures don’t apply to family
physicians.
CMS is working on developing new episode-based measures in
the future to fit diverse needs. Given below are the episode-based cost
measures.
- Elective Outpatient Percutaneous Coronary Intervention
- Intracranial Hemorrhage or Cerebral Infarction
- Knee Arthroplasty
- Revascularization for Lower Extremity Chronic Critical Limb Ischemia
- Routine Cataract Removal with Intraocular Lens Implantation
- Screening/Surveillance Colonoscopy
- Simple Pneumonia with Hospitalization
- ST-Elevation Myocardial Infarction with Percutaneous Coronary Intervention
- Acute Kidney Injury Requiring New Inpatient Dialysis
- Elective Primary Hip Arthroplasty
- Femoral or Inguinal Hernia Repair
- Hemodialysis Access Creation
- Inpatient Chronic Obstructive Pulmonary Disease Exacerbation
- Lower Gastrointestinal Hemorrhage
- Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
- Lumpectomy, Partial Mastectomy, Simple Mastectomy
- Non-Emergent Coronary Artery Bypass Graft
- Psychoses/Related Conditions Renal or Ureteral Stone Surgical Treatment
It is to be noted that cost measures are risk-adjusted
(based on the hierarchal condition category (HCC) risk scores) for the
difference in patients’ medical conditions. For Instance, for multiple chronic
conditions affecting physician’s performance.
The performance benchmarks are set based on the data
collected by the CMS.
A measure will be benchmarked if it has 20 groups or
individual clinicians who attribute to the measure’s minimum case.
For a fact, any measure without a benchmark cannot be scored
or included in the performance category scorecard.
Eligible clinicians can be assigned up to 10 points on
average of all scored cost measures concerning the performance benchmark.
For group participation in QPP MIPS, the final score will be
the aggregated value of all individual scores under the TIN.
For Instance, if a clinician has 8 attributes and another
has 12 attributed cases, so the group will receive a collective score as they
reached the minimum threshold point 20.
If any individual or group doesn’t receive a score for this category, the weight will be redistributed to the Quality performance category.
