Whitfield L. Knapple, MD, FACG
Chair, Legislative and Public Policy Council

MIPS and Larger Group Practices: Are larger groups unfairly treated in MIPS Quality Category?  What is ACG doing for you?

MACRA provides that the Centers for Medicare and Medicaid Services (CMS) may use global measures, such as global outcome measures, and population-based measures, for purposes of the quality performance category—and CMS is choosing to use this authority for group practices of 16 or more.  This will be included in the providers’ overall Quality score.  Practices do not actually report data.  Instead, CMS will calculate an “all cause hospital readmissions” population-based measure based on Medicare claims data.

For CY 2018, CMS states that the maximum quality performance score will continue to be 60 points for solo practitioners and groups of 15 or fewer clinicians (6 submitted measures x 10 points =60).  For group practices of 16 or more MIPS-eligible clinicians (not just physicians), this increases to 70 points.  CMS will also calculate an “all-cause hospital readmissions” population measure for your MIPS Quality score. The methodology:

  • 10 points for each of the 6 measures reported and 10 points for 1 population measure for groups of 16 or more.

What is this “population measure” that will impact the score of ACG members in larger group practices?  What has ACG been doing on this front?

The “30-day All-cause Hospital Readmission Measure” measures readmission rates for Medicare beneficiaries who were hospitalized, then have an unplanned readmission for any cause to a short-stay acute-care hospital within 30 days of discharge. The measure identifies providers by the group’s Medicare Tax Identification Number (TIN).  This measure is applied to groups of 16 or more who meet the case volume of 200 cases.

The measure is calculated from Medicare fee-for-service claims (Parts A and B) and Medicare beneficiary enrollment data.  This means that CMS does the work for you—no data submission by the group practice is required.  The measure uses one year of inpatient claims to identify eligible admissions and readmissions, as well as up to one year prior of inpatient data to collect diagnoses for risk adjustment.

Medicare patients gets assigned to a group practice’s TIN when the beneficiary has received more primary care services than other TINs treating the patient.

However, ACG continues to be concerned, as CMS has not provided any information on the reliability and validity of the measure when applied to physicians.  This measure has been endorsed by the National Quality Forum, but only for use in the hospital setting, and is currently reported in the CMS Hospital and Medicare Shared Savings Programs.  This is particularly important, because the Quality performance category represents 50% of your group’s MIPS score in 2018 (impacting CY 2020 reimbursement).  Essentially, CMS is treating group practices like hospitals for MIPS purposes, but without the reliability data.  What’s more, the hospital community continues to be concerned with the reliability, validity and usability of this measure even at the facility level.  The degree to which a physician can truly impact readmissions rates across all conditions is also not known, and limits the measure’s ability to be used for quality improvement and accountability.  In addition, there are concerns that there may be patient- or “community-level risk factors” outside of the control of the physician (e.g., living alone, poor access to medical care) that could impact readmission rates.  These factors are not currently included in the risk adjustment approach.  ACG will continue to work with CMS on improving claims-based metrics in MIPS impacting larger GI practices. It is important to have measures validated and tested for reliability prior to being included in MIPS.

MIPS and Solo Practitioners and Smaller Groups: CMS provides ways to improve your MIPS score?  What is ACG doing for you?

CMS defines a “small practice” as practices consisting of 15 or fewer MIPS-eligible clinicians.  CMS estimates that there are 11,298 MIPS-eligible GI clinicians in 2018. According to CMS estimates, 3% would receive a reimbursement cut in CY 2020, while 97% would be eligible for a bonus, or would at least avoid a payment cut.  However, ACG has significant concerns regarding the impact to small practices: CMS approximates that there are 116,626 MIPS-eligible clinicians in practice sizes 1 to 15. Of these practices, 9% are expected to receive a payment cut.  ACG has educated policymakers that, based on CMS’ own data, small practices clearly need more help when transitioning into MIPS.

Fortunately, CMS has listened to ACG and other stakeholders.  For the reporting year 2018, CMS will add 5 additional points to the total MIPS score to small practices (groups or individuals).  In order to receive this bonus, however, the provider or group must submit data on at least 1 MIPS performance category.

This is still welcomed news, as ACG has advocated on behalf of small and solo practices throughout the transition into MIPS, and continues to appreciate that CMS is recognizing the unique challenges that small and solo practices face when participating in MIPS.

What other ways can solo and small practices improve their MIPS score?

First, check to see whether you have to participate in MIPS.  ACG has advocated for higher threshold requirements for solo and small practices.   ACG is here to help navigate you through this process.

In the MIPS’ Quality performance category: For CY 2018, CMS the maximum quality performance score will continue to be 60 points for solo practitioners and groups of 15 or fewer clinicians (6 submitted measures x 10 points =60) .  The methodology:

  • 10 points for each of the 6 measures reported and 10 points for 1 population measure for groups of 16 or more.   Clinicians and groups who do not satisfy the 60% data completeness standard for a quality measure would receive 1 point.

However, CMS will continue to award small practices 3 points for measures that don’t meet data completeness requirements.

In the MIPS’ Advancing Care Information performance category:  All MIPS providers can still claim a hardship exemption for this performance category like you could under the old Meaningful Use program.  A MIPS-eligible clinician or group may submit a “Quality Payment Program Hardship Exception Application,” citing one of the following specified reasons:

  • Insufficient Internet Connectivity
  • Extreme and Uncontrollable Circumstances
  • Lack of Control over the availability of CEHRT

In 2018, however, CMS also expanded a hardship exemption to:

  • Solo practitioners and small groups (15 or fewer)

In the MIPS’ Improvement Activities performance category: CMS has a list 112 differently weighted “improvement activities.”  You can review and select activities that best fit your practice.   A simple attestation or “yes” is all that is required to completing an Improvement Activity.  You can earn a maximum of 40 points to receive the highest score for the Improvement Activities performance category.

However, CMS has finalized a different weighted system for small practices (groups of 15 and under), as well as those in rural areas to help achieve these 40 points.

ACG will continue to advocate on behalf of small and independent GI practices participating in MIPS.

Whitfield L. Knapple, MD, FACG

Chair, ACG Legislative and Public Policy Council