MIPS 2018 update: how to avoid MIPS penalties

This blog post is a continuation of my discussion on MIPS, the so called “quality” program for Medicare.

2018 reporting and performance will reflect on year 2020 medicare payments (similarly, 2017 performance reflects on year 2019 payments). The penalty has increased from 4% for last year’s reporting to 5%. Next year it will be 7% and then 9%.

The threshold for negative 5% adjustment is 15 points on the MIPS 0-100 scale. If you get over 15 points you won’t be penalized. Last year it was three points, all you had to do was submit one piece of data. The threshold for high performance remains at 70 points (more on this below).

The reporting period is now one year rather than 90 days.

For smaller practices, or most importantly for those of you starting practices and reading this blog, CMS has volume exemptions. The exemption has been increased from less than $30,000 Medicare in payments or 100 Medicare patients for 2017 to $90,000 in Medicare payments or 200 patients. Medicare advantage patients are not counted in this number, only traditional medicare. Many peds and plastics ophthalmologists might fall under this. If it is your first year in practice you are also exempt. I’m not clear on whether this is based on your NPI/TIN combination which would be more favorable for exemptions, or if you practiced with a group before you are not exempt even with your new solo practice. But being exempt may not be a good thing if you expect to meet the high performance bonus; it is not clear whether if you are under these thresholds if you are eligible to receive bonus payments for high performance.

Similarly, the penalties and incentives only apply to traditional Medicare patients, not those in Medicare advantage (replacement) plans.

There’s a new category called cost measures (formerly known as the value based modifier). In 2017 your score was based on three measures: quality was 60%, ACI (the old EHR meaningful use) 25%, and improvement activities 15%. In 2018 quality counts as 50% and cost 10% (ACI and improvement activities are same at 25% and 15%), in 2019 quality and cost each 30%.

So what how is cost measures calculated? And what do you need to do?

The answer is that you don’t need to do anything. It’s reported through your claims. Cost is based on two measurements, “total per capital cost measure” and “Medicare spending per beneficiary (MSPB)” and is turned into a percentile score. MSPB is for episodes for your TIN and is linked to you; total per capita is for both parts A and B so therefore most of this is probably beyond your control and your score will be higher if you practice in a socioeconomic area where patients take good care of themselves. Conversely, your score will probably be lower if you have many noncompliant patients. If you practice in an area where the other doctors order a lot of tests or do expensive procedures, this will also lower your score. Although there will be a “complex case bonus” of up to 5 points which may be related to how many dual eligibles (Medicare- medicaid patients) you see, I love how the government penalizes us for things that are beyond our control! Here is a good link that explains the cost measure scores.

As I previously stated, cost measures counted as zero in 2017, will be 10% of score in 2018, and will be 30% in 2019. In the future this will be episode based care- cost per heart attack, knee replacement, or cataract surgery….

In terms of how to report, quality, ACI and activities can all be reported through a clinical registry. Check to see if your medical society has one. For ophthalmologists, even if you aren’t enrolled in the IRIS (or any other) registry you can still attest on the CMS website for ACI (EHR use) and improvement activities. But it’s easy to do so through the registry. You can report quality with claims reporting or the registry, but again it’s easier with the registry.

One piece of good news is for small practices (under 15 practicioners) there is automatically a 5 point bonus if you submit any type of data besides cost. So for most of us reading this you need to only get 10 points on your own to avoid penalties.

Like 2017, 70 Points is the “high scoring” threshold. In 2018 from 15 points to 70 points the bonus gradually increases from zero to up to about 5%.  The money from people who got the penalty will be used to pay the bonuses up to 70 points so supposedly this is budget neutral. But since the penalties are easy to avoid, I doubt that there will be much of a bonus.

Over 70 points you could be eligible for up to a 18% bonus. I doubt this will happen, as for 2017 reporting it is estimated once the data is finalized the bonus will be up to 2.4% rather than the full 4%. And for 2018 reporting it might be 2.1% rather than the full 5%. That’s because the measurements were so easy to meet. But who knows. It seems like docs fall into one of two categories: those who don’t do anything and take the 4-5% penalty, or those with “high performance.” Tounge in cheek, I’m sure this was EXACTLY what CMS had in mind when they set up this program and forced doctors to spend money and time to meet these requirements.

At the seminar that I went to to hear about these changes, someone asked if there was any study correlation between MIPS score and patient outcomes. Who knows?!?  This whole nonsense is random but it’s not hard to beat the system and get a bonus, at least in 2017 and 2018.  Apparently through 2022, CMS has set aside a half billion dollars for high performing practices (over 70 points). It has been estimated that 74% of MIPS reporters will get a score over 70 for high performance, so whatever bonuses there are will be very minimal.

Finally, it was stated multiple times that this whole thing is a push to get groups to join ACOs as the reporting is through the APM (Advanced practice model), but even if you’re in a ACO you still need to do reporting to the ACO.

However, if you expect your score to be over 70 it might be better to NOT report through a ACO/ APM (advanced payment model) because the group could drag you down; you’d get a higher bonus reporting individually.

If anyone is interested here’s the 26 page report from CMS. Makes great Friday night reading!


These are helpful links that have more detail than my summary post. If you have access to a clinical registry or EHR reporting, you should easily be able to avoid penalties by reading the links below, even without spending thousands of dollars for consultants like the big groups do.



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