MHA FPX 5068 Assessment 1 Merit-Based Incentives and Daily Operations

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Capella University

MHA-FPX 5068 Leadership, Management and Meaningful Use of Health Care Technology

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Merit-Based Incentives and How They Affect Daily Operations

The Merit-Based Incentive Program System (MIPS) was established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This act came into effect in January 2017 and impacts the healthcare industry by transforming from a fee-for-service to a pay-for-value model. MIPS is designed to determine Medicare payment adjustments. Using a composite performance score, eligible clinicians may receive a payment bonus, a payment penalty, or no payment adjustment (Centers for Medicare and Medicaid Services [CMS], 2021). The organization reports the measures and activities they collect during the performance period. CMS collects and calculates cost measures for the organization. The four performance categories—quality, improvement activities, promoting interoperability, and cost—are scored and make up the final MIPS score. The payment adjustment applied to the Medicare claim is determined by the final score. Medicare’s legacy quality reporting programs were consolidated and streamlined into MIPS. This consolidation reduced the aggregate level of financial penalties physicians otherwise faced and also provides a greater potential for bonus payments (Rathi, 2019).

There may be benefits of MIPS, but there are also significant challenges. MIPS is a new reimbursement program for Medicare and Medicaid services that has both drawbacks and gains for provider payment. Lack of incentive is one drawback for providers participating in MIPS. Providers participating in an alternative payment model will be qualified to receive financial incentives. Providers in MIPS or fee-for-service reimbursement models will not be qualified to receive any bonuses and will have a lower reimbursement rate than those participating in alternative payments.

MHA FPX 5068 Assessment 1 Merit-Based Incentives and Daily Operations

Shortcomings in aligning stakeholders is a further challenge that MIPS faces. Simplifying quality measures under alternative reimbursement programs and MIPS, like the Physician Quality Reporting System, will help decrease this challenge. To benefit beneficiaries, it is important for quality data to be in a user-friendly form (Berdahl et al., 2019). Challenges with documentation standards create difficulties in aligning beneficiaries among payers and providers. The lack of alignment between Medicare, Medicaid programs, and commercial payers regarding quality measures has led to a significant burden on providers concerning performance improvement (Johnson et al., 2020). It is vital for organizations to collaborate with payers, providers, healthcare associates, and quality measurement professionals to reduce challenges with the payment system.

According to Eggleton et al. (2020), there are three exclusions of providers from MIPS eligibility. First, providers participating in an APM, as defined by MACRA, are not qualified to participate in MIPS. Second, clinicians who report less than $90,000 in Medicare beneficiaries in a specified period or provide services to less than 200 Medicare patients a year are exempt from MIPS. CMS conducts low volume status determinations prior to and during the performance period using claims data. Finally, providers who enroll in Medicare for the first time during a performance year are exempt from MIPS until the next subsequent performance year.

Meeting Measures of Merit-Based Incentives

With the implementation of MIPS, providers were challenged with limited knowledge of ways to adequately meet measures to prevent penalties. It is imperative for clinicians to select appropriate measures. Clinicians must evaluate and identify their organization’s strengths and weaknesses with quality reporting (Rutherford et al., 2017). After identifying strengths, clinicians should utilize MIPS measures that will maximize performance. Eligible clinicians can receive maximum points by reporting on only six of 271 quality measures and four of 93 improvement measures. Practices should invest in MIPS technology to assist with incentives and avoid penalties. Collaborating with current EHR vendors enhances clinician productivity, increases MIPS performance scores, and supports the additional benefit of EHR support. It is vital for the EHR system to have the ability to incorporate reporting requirements into clinician workflows.

With the assistance of the EHR system, organizations can anticipate positive MIPS payments and avoid penalties. Currently, providers’ positions on MIPS have hampered implementation. Utilizing physicians to educate their peers on MIPS and its financial implications may assist with MACRA implementation challenges (Horvitz-Lennon et al., 2022). It is important to motivate staff across the organization to work as a team to achieve MIPS goals (Horvitz-Lennon et al., 2022). Utilizing a physician as a MIPS champion can help overcome the reluctance towards MIPS. This will also incorporate clinical experiences with MIPS requirements without compromising quality patient care. According to LaPointe (2017), healthcare organizations should utilize one to two physicians to become MACRA implementation experts.

MHA FPX 5068 Assessment 1 Merit-Based Incentives and Daily Operations

It is crucial for organizations and clinicians to ensure coding and clinical documentation is accurate to meet the program’s data completeness requirements and maximize MIPS incentives. If an organization fails to submit the necessary data, it will receive zero points on a MIPS measure. Ensuring that coding and clinical documentation advancements are accurate is crucial to improving MIPS performance scores. Additionally, ensuring clinicians are prepared for MIPS is essential to avoiding penalties and maximizing performance. Provider organizations can assist their clinicians in avoiding penalties by educating them on MACRA implementation processes and providing access to MIPS support. Organizations and providers who use MIPS successfully protect their financial future by increasing incentives and avoiding penalties. They gain staff buy-in by aligning MIPS goals to what motivates their staff.

Another advantage is empowering a quality champion to provide insight and take the reins on achieving MIPS goals. Finding and using MIPS resources to their advantage and optimizing their EHR system to support quality measurement is beneficial. The financial and reputational impacts of the MIPS score are affixed to a clinician, even if the clinician moves to another organization or practice. For example, if a clinician earns a MIPS score for 2020 and works for another organization in 2021, the new organization will inherit the MIPS payment adjustment applied in 2023 based on the 2020 score earned by the clinician at the previous organization (Berdahl et al., 2019). Additionally, every MIPS score earned by a clinician is a permanent part of the public record released and maintained by CMS, making MIPS scores an increasingly significant portion of a clinician’s resume (Berdahl et al., 2019).

Impact of Failing to Meet Measures of Merit-Based Incentives

The MIPS program determines quality measures and reporting requirements for eligible clinicians and hospitals. Several conditions vary depending on payment implications. One condition is whether a clinician is participating in MIPS, a MIPS alternative payment model (APM), or an advanced APM. The most significant impact an organization will encounter is the possible penalty fees for not meeting quality benchmarks. Another significant impact is for organizations that do not participate in MIPS. Organizations and clinicians eligible for MIPS will obtain a 7% payment increase within the Medicare fee schedule as well as a possible bonus payment for performance scores. The impact of not participating in MIPS is receiving only a half-percent rate increase to their Medicare fee schedule with a potential quarter-percent increase within a few years (Berdahl et al., 2019). Organizations that do not participate in MIPS will also miss a 3-10 percent bonus as a top-performing hospital. These additional reimbursements can be utilized for improvements to patient care and guaranteeing the hospital continually sustains itself as a high-quality care organization. Participation in MIPS offers incentives and allows clinicians to assess their practice and ways to constantly improve. Clinicians who decline to participate in MIPS face the challenges of a fee-for-service reimbursement payment system and the opportunity to improve their practice and provide higher quality care for patients (Berdahl et al., 2019).

Conclusion

There are various methods for management and leadership that could assist departments and end-users in meeting and remaining compliant with Merit-Based Incentive Program requirements. It is imperative that Vila Health improve their performance scores in the MIPS categories to qualify for full payment. It is vital that eligible clinicians and healthcare managers are educated on the measure requirements for MIPS. This knowledge will allow clinicians to leverage the MIPS reporting flexibilities and maximize their composite performance scores. This will result in avoiding the negative nine percent penalty by selecting MIPS measures that the organization performs well on already.

It is important that Vila Health partners with EHR and Health IT Vendors for support to integrate MIPS reporting requirements into clinician workflows. This will allow for scores to be regularly viewed and enhancements made when needed. Implementing clinical documentation support in the EHR will also allow for data completeness, ensuring the coding and clinical documentation is precise according to MIPS guidelines. Finally, it is crucial that organizations identify a physician as a champion to facilitate MIPS education and performance improvements. Utilizing physicians to educate their peers on the importance of clinician workflows that combine MIPS requirements without compromising patient care and other clinical responsibilities would alleviate MACRA implementation challenges (Rutherford, 2017).

References

Berdahl, C. T., Easterlin, M. C., Ryan, G., Needleman, J., & Nuckols, T. K. (2019). Primary care physicians in the merit-based incentive payment system (MIPS): A qualitative investigation of participants’ experiences, self-reported practice changes, and suggestions for program administrators. Journal of General Internal Medicine, 34(10), 2275-2281. https://doi.org/10.1007/s11606-019-05207-z

Centers for Medicare and Medicaid Services (CMS). (2021). Physician quality reporting system (PQRS) overview. CMS.gov. https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/downloads/PQRS_overviewfactsheet