June 5, 2018: Board members of the American Medical Group Association requested that Congress reduce or remove the MIPS eligibility thresholds for participation (as reported in Modern Healthcare). Currently only 39% of the 1.5 million Medicare clinicians that would be eligible for the MIPS are participating in 2018. They argued that low participation rates reduce the amount of revenue available from practices that would have otherwise received negative payment adjustments, impeding the goals of the program to transition practices to value-based care.
Under the MACRA statute funds from negative payment adjustments are used to fund positive payment adjustments to practices with high MIPS performance. The process needs to be budget neutral.
The MIPS eligibility thresholds are based on patient volumes or Medicare Part B Physician Fee Schedule allowed charges. They are determined at the individual clinician or group practice level if the practice elects to report as a group. If the clinician/group is not above either threshold they are excluded from the MIPS.
In 2017 these thresholds were over 100 Medicare Part B patients or over $30,000 in allowed Medicare Part B charges. In 2018 the thresholds were raised to over 200 patients or more than $90,000 in allowed charges.
Discussion: Changes to the eligibility thresholds may or may not increase funds available to reward high performing practices. This assumes that clinicians/groups with lower volumes of Medicare Part B patients and allowed charges will in general have poorer performance MIPS that organizations with higher volumes. This is yet to be proven although practices with lower volumes of Medicare Part B patients may not be as incentivized as higher volume practices. The potential negative and positive payment adjustments will have less financial impact.
The primary cause of the reduced pool of funds (and not mentioned in the article) are the MIPS performance thresholds. The performance thresholds are used to determine negative, neutral and positive payment adjustments. Practices that have MIPS scores below the threshold receive negative payment adjustments. Practices with scores at the threshold have no adjustment, and those above the thresholds receive positive adjustments proportional to their score.
Under MACRA the performance threshold is determined by the mean or median scores of all MIPS participants, however CMS was given the flexibility to set the value during the first two transition years of MIPS. The 2018 Bipartisan Budget Act of 2018 extended this flexibility for three additional years. It will not be until the 2022 performance year that CMS will be obligated to allow the MACRA performance thresholds to be determined by performance alone. Once this goes fully into effect just under 50% of all MIPS participants will receive an negative payment adjustment and just under 50% will receive a positive payment adjustment.
In 2017 the MIPS performance threshold was set to 3 points, and an estimated 4% of MIPS eligible clinicians/groups will receive negative payment adjustments. In 2018 the performance threshold was raised to 15 points. A small proportion of clinicians are expected to score below this value, again markedly reducing the funds available to reward high performers.
MACRA allocated a pool of $500 million dollars to fund an “additional payment adjustment” for the first 6 years of MIPS. These funds are distributed to practices that achieve performance scores above an additional payment threshold. For the first 5 years of the MACRA program CMS will be allowed to set this value. Starting in 2022 it will be set at a value that is 25% between the MIPS performance threshold and 100 points.
CMS set the additional payment threshold to 70 points in 2017 and 2018. Most practices are expected to achieve scores above this value in 2017 and 2018, which will markedly dilute these funds. Congress and CMS may wish to consider how this value is determined in future years to create a great incentive for high performing practices.
The Modern Healthcare Article is available here: Doctors urge Congress to eliminate MACRA opt-out policy
This page was last reviewed/updated on June 6th, 2018.
Author: Michael Stearns, MD, CPC, CFPC
Author contact information: firstname.lastname@example.org