Introduction to Afoundria’s MIPS Education Series

MIPS! Everything is going to be OK.

Over the next couple months, we will be publishing a series of materials on MIPS and the specific steps you need to take to prepare for it. There is a lot of noise out there, and it can be difficult to figure out what the future holds. Our goal is to breakdown this noise, help you understand how MIPS can affect your long-term and post-acute care practice, and give you the tools you need to succeed. If you have any questions, our team is always here to help you! You can reach out to support@afoundria.com.

Medicare’s new Merit-based Incentive Payment System (MIPS) kicks off in 2017. Your score this year will affect your Medicare reimbursements in 2019. The threshold this year is EXTREMELY low; to ensure that you don’t receive a penalty in 2019 reimbursements, you simply need to score a 3 out of 100. I think we all wish the pass/fail threshold in college and med school was only 3%.

Not surprisingly, there are folks out there “guaranteeing” a score of 100% for 2017. This will be significantly difficult for LTPAC practices and next to impossible in general. We recommend reading these messages with a grain of salt as this guarantee falls squarely into the “too good to be true” category. If an EMR company, especially, tells you they can get you a perfect score, they are lying. Just purchasing a certified EMR will only get you about 12 points, how you use it will allow you to capture the full 25 points associated with technology.

MIPS Background

MIPS is Medicare’s new Part B payment model for physicians. MIPS replaces the sustainable growth rate (SGR) and the physician quality reporting system (PQRS) and sprinkles a little Meaningful Use on top. Medicare is allocating $26 Billion for physicians and providers, but only 600K providers will be eligible (if you are an Afoundria customer, it is HIGHLY likely that you will not be excluded from MIPS). Eligible providers are those who bill Medicare more than $30,000 in 2017 or who see more than 100 Medicare patients.

MIPS is the push from volume-based reimbursement to value-based reimbursement. This means that over a period of 4 years, Medicare is going to shift physician and provider payments from the traditional 100% fee-for-service to a mixture of fee-for-service and quality/cost performance. The better your outcomes and the lower your cost, the higher your payments.

This is being funded as a “zero sum” program; additional funds are not being allocated to Medicare and funds will not be taken away from Medicare. This is accomplished by penalizing low performing providers and giving bonuses to high performing providers. These penalties and bonuses ramp up over the next four years.

Breakdown of Bonus/Penalty by Year

Measurement Year Payment Year Penalty/Bonus
2017 2019 -4% to 4%
2018 2020 -5% to 5%
2019 2021 -7% to 7%
2020 2022 -9% to 9%

The penalty and bonus amounts will vary by provider, it’s not binary. Based on your score, you will receive a payment adjustment somewhere between -4% and +4% in 2019. But neither a full penalty or full bonus is realistic (see below in “The Truth about MIPS Scoring and Your Bonus).

MIPS is NOT a part of Obamacare and efforts by elected officials to repeal and replace the Affordable Care Act will not affect MIPS. Modifying the MIPS program would take a separate act of Congress. We have seen the softening of the MIPS rules and structures and we can expect to continue to see this. For example, the original scoring threshold in 2017 to avoid 2019 penalties was significantly higher (around 50%) and has now been reduced to just 3%.

The Truth about MIPS Scoring and Your Bonus

The real truth about your MIPS score in 2017 is that no matter what, your bonus or penalty will be minimal. This is due to two factors. First, bonuses and penalties are based on comparative scores. So it’s not how well you do, it’s how much better or worse you are than your peers. This is similar to bell curve grading. The second factor is that the threshold for 2017 scores is very very low and a significant majority of providers will be able to meet this. Everyone who scores at least 3% in 2017 will avoid a penalty for 2019 payments. The threshold is preset and not determined by the average score of all participating providers.

The providers who score very high (top 25% of total providers) will receive a bonus. The money for this bonus will come from the money saved by issuing penalties to low performers. Because the threshold is so low and so easy to reach, there will be very few providers who qualify for a penalty, which means there will be very little funding for bonuses. It would be virtually impossible to issue 4% bonuses to high performing providers because there simply wouldn’t be enough money to go around. Similarly, because there will be very little money allocated for bonuses, the total providers receiving a meaningful bonus will be very small.

The keys for 2017 activities should be to do enough to reach a score of 3 out of 100 and to prepare for 2019 and 2020 measurement where more focus will be placed on quality, improvement, and cost. Even in 2018, the threshold score is expected to only be 15%.

What role does CEHRT play in your MIPS score?

In 2017, CEHRT technology actually plays a very small role in your MIPS score. The total points allocated for Advancing Care Information (the category in MIPS related to using CEHRT technology) is only 25% of your score, and that’s if you have met every requirement starting January 1, 2017. To reach the minimum score for this category (about 12 percentage points), you will need to attest to using CEHRT to accomplish a number of tasks. While this isn’t difficult, there are a number of other strategies to get to the minimum threshold score of 3%. If you want to take the ACI approach, we can absolutely get you there. And if you are targeting the best MIPS score possible, we can get you there as well.

The real truth about CEHRT and MIPS is that starting next year, the technology you use must be 2015 certified and you must use it from January 1 through December 31. There are actually very few EHR’s on the market with 2015 certification. Afoundria is currently seeking 2015 certification with an expected certification date in September of this year. This means you will be completely covered next year when CEHRT really matters. Our competitors cannot say the same!

What does MIPS mean for your PALTC practice?

For our users, 2017 should be about “gearing up” for MIPS in full swing (years 2019 through 2020 and beyond). Avoiding the 2019 penalty with 2017 activities is very simple and the scoring in 2018 will be similar. When MIPS starts ramping up the success threshold, we want our users to be prepared and when you are prepared, it really is pretty simple.

Much of MIPS is designed around the ambulatory practice of medicine where the provider/patient relationship is more established and longer term. This isn’t the case in PAC. The effect of this is that many of the quality categories (like Diabetes) that work well for ambulatory providers don’t make a lot of sense for PAC providers. We’ll be going through this in more detail in the future so you will have a better idea of the appropriate measures on which to report.

What should we do now?

MIPS in 2017 is VERY EASY because the scoring threshold to avoid the penalty is very very low. This means almost every provider can and will reach the threshold which ultimately leads to a very small bonus pool. The targeted 4% bonuses will be virtually impossible to reach and, if our math is correct (we all passed our statistics classes in college), the highest bonuses from MIPS will likely be in the .5% - 1% range. That’s a $1,000 bonus for every $100,000 you are paid by Medicare AT BEST in 2019. Is that worth the cost and effort to get the highest score possible? We don’t necessarily think so.

In fact, the only way to get the highest bonus is to score near 100% which means you must report on 365 days worth of data and have all other categories (quality and practice improvement) in place and being measured since January 1. The industry actually expects VERY FEW providers to fall into this category with the majority of providers meeting the minimum threshold of 3%.

So our recommendation is to get the 3 necessary percentage points to avoid the penalty and focus on preparing for years 2019 and 2020. One very simple way to do this is for every provider in your practice to bill a G-Code. There are some other strategies related to ACI that you can do that will give you a score beyond the 3% and we’ll dive into those in our ACI post. It’s not a simple as just billing a G-Code, but it is pretty simple.