December 05, 2018

Navigating the Ins and Outs of MIPS

There may be no better person than Gregory N. Nicola, MD, FACR, to offer guidance on the intricacies of the Merit-Based Incentive Payment System (MIPS).

The chair of the American College of Radiology (ACR) MACRA Committee updated attendees at the Radiological Society of North America (RSNA) Annual Meeting last week on recent changes to the value-based Medicare physician payment program. Advocacy in Action interviewed Nicola by phone after the event about his observations. Here are his responses to our questions.

AIA: How would you characterize the current state of MIPS?

Nicola: It is constantly in flux, though at this point, participating physicians aren’t seeing a lot of upside positive income adjustments or downside penalties. Radiologists should stay tuned and continue to participate because the downside penalties will continue to escalate, leading to an exponential increase in the upside financial incentives of MIPS.

AIA: What could happen as the MIPS moves toward full implementation?

Nicola: An animated sequence in my presentation showed what happens over the next few years to the MIPS performance threshold, the dividing line between physician winners and losers. As the performance threshold creeps up, so does the number of losers and amount of money that can be paid to the winners. By the time the program is fully implemented in 2022, the difference between upside money and downside money can theoretically be on the order of 37 percent on the upside and a minus nine percent on the downside.

AIA: How will recent updates affect the program?

Nicola: Originally, MACRA statute mandated that the cost-performance category of the MIPS had to be worth 30 percent of the eligible physicians’ final scores by the 2019 performance year. In 2018, it currently accounts for 10 percent. The Balanced Budget Act of 2018 allowed the Center for Medicare and Medicaid Services to slow down this process, so cost performance doesn’t need to be fully implemented until 2022. The 2019 Quality Payment Program final rule established a time table by raising the impact of cost measures in increments of five percent points per year until it reaches 30 percent by 2022. Every time the impact of cost on the physicians’ MIPS scores goes up five percent, the impact of quality goes down five percent.

AIA: Your slides indicate the Quality Performance Category involves six total measures including one outcome. Does that mean participating radiologists need to choose six measures and one outcome to measure their performance for MIPS in 2018 and again in 2019?

Nicola: That’s correct. They should pick six measures, one of which should be an outcome measure. If there isn’t an outcome measure, they can pick a designated high priority measure instead.

AIA: In your RSNA presentation, you emphasize that “The MECHANISM you use to report ... MATTERS!” Why does it matter?

Nicola: You want to select the mechanism that provides the most useful measures and the most flexibility. For radiologists, qualified clinical data registries, like the American College of Radiology’s National Radiology Data Registry (NRDR), tend to have the most relevant measures for radiologists and measures that have relatively higher priority, meaning that there will be bonus points to share. Also, if you electronically report your data, you get bonus points as well.

AIA: You also stressed the importance of the measures selected by individual radiologists or imaging group practices for their participation in MIPS by saying, “The MEASURES you choose to report ... MATTER!”. Why is measurement selection important to your performance and the potential quality improvement and financial benefits of MIPS participation?

Nicola: Just because you do well on a measure 99 percent of the time doesn’t means you’ll get a high score. If everyone else performs at the 99 percent level, you’re just average, meaning you’ll just get five points out of a possible 10, for example. So, you’ve got to be smart about picking measures. You’ll want to pick measures you perform much better than the set benchmarks of other radiologists who have submitted the same measure. Look for high priority measures, such as outcome measures and patient safety measures that have associated bonus points. And avoid ‘topped out’ measures that Medicare thinks are so easy that everyone will do them well. Medicare published a table listing all of them in 2018, but it has yet to publish a table for 2019. We won’t know what they are until the end of December, but you be sure to look for them. They will be vitally important for your 2019 performance year.

AIA: What do radiologists need to do to plan for MIPS in 2019?

Nicola: For the first time, claims data may only be submitted by individuals or small groups of 15 or fewer eligible clinicians. Radiologists must submit quality data for the whole year and in many cases for 60 percent of their patients for each quality measure. They will again be required to collect 90 days of data for improvement activities.

AIA: What resources do you recommend to radiologists to learn more?

Nicola: I would start at the MACRA Resources Page on the ACR website. You should look for past articles in the Journal of the American College of Radiology. The 15 or so MIPS-related articles my colleagues and I have published in it over the past 18 or so months summarizes the program nicely. And we are about to record a new ACR webinar on MIPS and its 2019 updates. It will be shown live in mid-January.