What Is MIPS?
MIPS stands for the merit-based incentive payment system, a program implemented by the Centers for Medicare and Medicaid Services (CMS) as part of its Quality Payment Program (QPP). MIPS is designed to incentivize healthcare providers to deliver high-quality care, improve patient outcomes, and reduce healthcare costs. MIPS measures and adjusts Medicare reimbursements for eligible clinicians based on their performance across several key areas of care.
The goal of MIPS is to shift healthcare from a volume-based system to a value-based system, where healthcare providers are rewarded for improving the quality and efficiency of the care they provide to patients.
What Is MACRA?
The Medicare Access and CHIP Reauthorization Act, or MACRA, is a landmark healthcare reform law that is transforming the way healthcare providers are reimbursed under Medicare. By shifting the focus from volume-based care to value-based care, MACRA encourages providers to improve patient outcomes, reduce unnecessary costs, and adopt health information technology, like EHRs. Healthcare providers can participate in MIPS for individual performance evaluations or alternative payment models for participation in more comprehensive, coordinated care models.
What Is the Quality Payment Program?
The Quality Payment Program (QPP) is a comprehensive initiative established by the under MACRA to improve the quality of care, enhance patient outcomes, and reduce healthcare costs through value-based care models. The QPP replaces the previous sustainable growth rate formula, which was used to adjust Medicare payments based on physician reimbursement rates.
With the QPP, focus is shifted from fee-for-service—in which healthcare providers are paid for the volume of services they deliver—to value-based care, which means providers are paid based on the quality and efficiency of care they deliver. Under the QPP, healthcare providers are incentivized to provide higher quality, patient-centered care while managing costs.
The QPP has two distinct paths for healthcare providers to follow MIPS and alternative payment models (APMs). Both pathways are designed to encourage better care and improve healthcare outcomes, but they differ in terms of reporting requirements, incentives, and the way providers are evaluated.
Who Does the QPP Impact?
The QPP is a key initiative from CMS that primarily impacts healthcare providers who bill Medicare for services. However, its influence reaches beyond just those providers, affecting a broad range of stakeholders across the healthcare system. Here’s a breakdown of who the QPP impacts:
Eligible Clinicians
The QPP applies to a wide range of Medicare Part B providers, including those who bill Medicare directly for outpatient services. The program impacts healthcare professionals such as physicians, nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists, and, under certain conditions, social workers.
For MIPS, eligible clinicians are generally those who have Medicare Part B charges of more than $90,000 annually or who provide care to 200 or more Medicare beneficiaries. However, some clinicians may be exempt or qualify for exclusions based on factors such as low volume of Medicare patients.
Healthcare Organizations and Practices
Impact of the Quality Payment Program (QPP) on Healthcare Practices and Organizations
Individual Practices: Smaller medical offices and independent practitioners must meet performance requirements in MIPS. The program encourages these practices to adopt quality improvement strategies, reduce unnecessary costs, and use EHRs for better care coordination.
Group Practices: Group practices, which may include multispecialty groups or large networks of physicians, also participate in MIPS. For group reporting, performance is measured across the entire group, and the resulting score affects the group’s overall Medicare reimbursements.
Accountable Care Organizations (ACOs): ACOs, which are groups of healthcare providers and hospitals that work together to deliver coordinated care for Medicare patients, are involved in alternative payment models (APMs) and can receive incentives for meeting quality and cost goals. ACOs can be exempt from MIPS if they meet the APM criteria.
Hospital Systems: Larger hospital systems that participate in ACOs or other bundled payment models are directly impacted by QPP’s APM track. Hospitals that are part of these models are incentivized to focus on value rather than volume of care delivered.
Medicare Patients
While patients are not directly required to participate in the QPP, people who use Medicare are significantly affected by its focus on improving care quality and reducing costs. The emphasis on quality metrics and care coordination encourages healthcare providers to focus on delivering more effective and patient-centered care. This can lead to improved patient outcomes and a better overall experience.
The goal of reducing unnecessary healthcare spending also benefits patients by lowering the overall costs of care. In the long term, this could lead to lower premiums and out-of-pocket costs for Medicare beneficiaries.
Healthcare IT Vendors and EHR Developers
The use of health information technology plays a central role in the promoting interoperability category of MIPS. The QPP strongly encourages the use of EHRs, health information exchange (HIE) systems, and other digital tools to enhance care coordination and patient engagement.
EHR and healthcare IT vendors must meet specific requirements to ensure their systems are certified for use in QPP reporting. Providers are required to use certified EHR technology to participate in QPP, and this provides an opportunity for vendors to develop products that help clinicians meet these requirements.
Healthcare IT consultants who assist practices in meeting QPP requirements can also be impacted. They may offer services to help organizations optimize their EHRs for meaningful use, improve their reporting processes, and adopt new technologies to comply with the QPP.
Payers and Insurers
Insurance companies, including Medicare Advantage plans, are impacted by the QPP as they must align with the program’s goals to ensure providers meet quality and cost benchmarks. They may also need to track provider performance and incentivize practices to participate in value-based care models.
Medicare Advantage plans are affected by the QPP in that they must consider quality and cost metrics when evaluating the performance of healthcare providers. These plans may have incentive structures based on similar quality metrics used in the QPP.
In the private insurance market, insurers may adopt some aspects of the QPP’s value-based models, pushing providers to meet similar quality and cost standards.
Insurers may begin to shift their payment models to align with the QPP, rewarding providers for quality care rather than the volume of services delivered. Insurers may also work with providers to implement quality improvement programs, such as care coordination, that align with the QPP’s goals.
Regulatory and Policy Makers
At a broader level, policy makers and regulators in the healthcare sector are directly impacted by the QPP because it shapes the way Medicare payment policy is crafted. It serves as a model for how reimbursement systems in both public and private healthcare sectors can be aligned toward improving value and outcomes.
What Are Alternative
Payment Models?
Alternative payment models, or APMs, are a more advanced alternative to traditional fee-for-service care. Under APMs, healthcare providers are incentivized to deliver coordinated care, improve patient outcomes, and reduce unnecessary healthcare costs, typically through models like accountable care organizations (ACOs), bundled payments for care improvement (BPCI), and patient-centered medical homes (PCMHs).
Providers who participate in advanced APMs are generally exempt from MIPS but instead must meet specific quality and cost benchmarks established by the APM. In these models, providers assume some level of financial risk for their patient populations, meaning they are responsible for the total cost of care and must demonstrate that they can deliver quality care while managing costs.
Key Features of APMs include risk-sharing, in which providers take on financial risk by being responsible for meeting quality and cost targets; incentive payments, in which providers who meet or exceed the quality and cost benchmarks can receive additional financial incentives, such as bonus payments; and exemption from MIPS, meaning providers in advanced APMs are not subject to MIPS since their performance is evaluated within the APM framework.
To qualify as an advanced APM, a model must meet certain requirements, including:
Use of certified EHR technology to
exchange patient information.
Performance on quality measures,
similar to MIPS quality measures.
Financial risk for
patient outcomes.
What Is the MIPS Composite Score?
The MIPS Composite Score measures performance across the categories of quality, cost, improvement activities, and promoting interoperability. The score is used by CMS to determine whether a provider will receive a positive, neutral, or negative payment adjustment to their Medicare Part B reimbursements.
Providers with higher composite scores are rewarded with better reimbursement rates, while those with lower scores may face financial penalties. Providers who score near the performance threshold may receive neutral adjustments, meaning their payments will not change.
Can I Participate in MIPS without an EHR?
MIPS does not specifically require EHR technology for participation, but promoting interoperability, one of the four performance categories in MIPS, is focused on the use of EHRs and health information technology.
If you participate in MIPS without an EHR, your ability to score well in the promoting interoperability category will be significantly impacted. Providers without an EHR system will receive a 0 score in this category, which is 25% of the total MIPS score. Missing out on the category’s points can significantly lower your overall MIPS score, potentially resulting in a negative payment adjustment.
What Is the Impact of Not Using an EHR on the Promoting Interoperability Category?
The promoting interoperability category measures how well you use certified EHR technology (CEHRT) to improve care quality and coordination. This includes data exchange with other providers; patient engagement through access to health records, online portals, and communications; and interoperability to allow data to be shared securely and seamlessly.
Without an EHR system, you'll have difficulty meeting any of the required promoting interoperability objectives. Meaningful use of an EHR is essentially a core requirement in this category.
Is There an Alternative to Using an EHR for Promoting Interoperability?
If you are unable or unwilling to adopt an EHR, you might still be able to report on the improvement activities category, which is 15% of your MIPS score. This category focuses on activities that improve care quality, such as care coordination, reducing hospital readmissions, and increasing patient access to care, and does not require an EHR.
However, it’s worth noting that even in the improvement activities category, certain activities may require basic digital tools or the ability to exchange health data to meet some of the requirements.
You may still report on quality measures (30% of your score) and cost measures (30% of your score) using claims-based data, but these areas are not as flexible as promoting interoperability. Without an EHR, providers often find it more difficult to meet quality reporting requirements for specific measures related to clinical outcomes or patient engagement.
If you use a paper-based system or non-EHR technology, your ability to participate in MIPS effectively might be limited. MIPS encourages practices to adopt health IT solutions, so even if you are not yet ready for a full EHR system, some practices use basic digital tools to improve reporting efficiency and ensure compliance.
Is Adopting an EHR Worth It for MIPS Participation?
While adopting an EHR can be an investment, it is a critical tool for maximizing your MIPS score. Enabling your practice to improve care coordination, reduce errors, and improve patient outcomes. Positioning your practice for future participation in value-based care models (such as APMs), which often require the use of an EHR. Furthermore, EHR incentives under other programs, such as the promoting interoperability category, might help offset initial costs.
How Can CureMD Help Me with MIPS?
One of the key challenges of MIPS is the reporting of data across various categories, which can be complex and time-consuming. CureMD simplifies this process by providing an integrated platform that enables you to:
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Automate MIPS reporting: CureMD’s EHR system helps automatically collect and submit data for the quality category, including clinical quality measures. This minimizes manual data entry and ensures that your performance is accurately reported.
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Generate and track MIPS reports: With CureMD’s MIPS dashboard, you can easily track your performance in real time and generate reports that help you assess where your practice stands across all four MIPS categories: quality, cost, promoting interoperability, and improvement activities.
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Customizable reporting: CureMD’s tools allow you to select the most appropriate measures for your practice, track progress, and make adjustments to improve scores.
Our dedicated MIPS consulting team can assist with getting you started. Please call 717-680-8500 or email us at qp@curemd.com
