The Cost Category Balancing Act: Proposed Changes for MIPS 2019 Part III

Evaluating the cost of care alongside the quality of care is not new. It was an element of PQRS program (QRUR reports) and with MIPS, CMS aspires to make further progress in this area. Reduction of cost would be meaningless if it leads to poor patient outcomes. However, a meaningful reduction in costs can be achieved by making clinicians aware of the cost of drugs and procedures they prescribe and reward them for better outcomes. With the proposed changes for MIPS 2019, CMS aims to move closer to striking the delicate balance between Cost and Quality of care. 

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In 2017, the transition year to MIPS, the Cost measures were evaluated, not scored. In 2018, Year 2 of MIPS, clinicians will be assessed on only two measures as the episode-based measures were being evaluated. However, for 2019, Year 3 of MIPS, CMS is ready with eight new episode-based measures along with higher weightage for Cost category.

Cost Category Weight - 15%

The Cost performance category weight for 2019 Performance Year is proposed to be 15% (up from 10% in 2018). Thanks to the Bipartisan Budget Act, it will not be increased to 30% for 2019 as was proposed in the 2018 QPP Final Rule.

Cost Reporting

Just like previous performance years, no submission is required for the Cost Performance Category. CMS will calculate performance on Cost measures from the Medicare Administrative Claims for the entire calendar year (Jan 1, 2019 to Dec 31, 2019).

SUBMISSION OPTIONS FOR COST CATEGORY

Performance Category
Collection Type for
Individual
Collection Type for
Group
Submission Type
Cost
-
-
No data submission required

Cost Measures

Eight new episode-based measures have been proposed to be added for 2019 in addition to the two measures for the current performance year 2018 (Total Per Capita Cost and MSPB). That makes it a total of 10 measures. The 8 episode-based measures have been subdivided into Procedural Episode Measures and the Acute Inpatient Medical Condition Episode Measures. Following case minimums and the attribution criteria are set in order to be able to score these measures reliably.

ATTRIBUTION CRITERIA & CASE MINIMUMS

Cost Measures
Case Minimum
Attribution of Medicare Beneficiaries to Clinicians
Total Per Capita Cost Measure
20
Majority of primary care services rendered by the clinician to determine attribution for the total per capita cost measure
Medicare Spending Per Beneficiary (MSPB)
35
Majority of Part B services billed during the index admission to determine attribution for the MSPB measure
Procedural Episode Measures (5)
10
Episodes attributed to each MIPS eligible clinician who renders a trigger service as identified by HCPCS/CPT procedure codes
Acute Inpatient Medical Condition Episode Measures (3)
20
Episodes attributed to each MIPS eligible clinician who bills inpatient evaluation and management (E&M) claim lines during a trigger inpatient hospitalization under a TIN that renders at least 30% of the inpatient E&M claim lines in that hospitalization

The Episode-based measures are developed to inform the attributed clinicians about the cost of the care they deliver. The cost for only the items and services that are related to an episode of care for a clinical condition or procedure are accounted using Medicare Parts A and B fee-for-service claims data. These costs are based on Episode groups which:

  • Represent a clinically cohesive set of medical services rendered to treat a given medical condition
  • Aggregate all items and services provided for a defined patient cohort to assess the total cost of care.
  • Are defined around treatment for a condition (acute or chronic) or performance of a procedure.

Items and services in the episode group comprise of treatment services, diagnostic services, and ancillary items and services directly related to treatment (such as anesthesia for a surgical procedure). Following 8 measures are proposed for 2019 MIPS performance year.

EPISODE-BASED MEASURES PROPOSED FOR MIPS 2019

Meaure Topic Measure Type
Elective Outpatient Percutaneous Coronary Intervention (PCI) Procedural
Knee Arthroplasty Procedural
Revascularization for Lower Extremity Chronic Critical Limb Ischemia Procedural
Routine Cataract Removal with Intraocular Lens (IOL) Implantation Procedural
Screening/Surveillance Colonoscopy Procedural
Intracranial Hemorrhage or Cerebral Infarction Acute inpatient medical condition
Simple Pneumonia with Hospitalization Acute inpatient medical condition
ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI) Acute inpatient medical condition

Cost Score Calculation

The score for the Cost category for 2019 will be calculated in the same way as that for 2018. Each measure will be scored out of 10 points based on the measure benchmarks.

Cost Achievement Points/Total Available Points = Cost Performance Category Percent Score

This percent score cannot not exceed 100%. The percent score will then be multiplied with the Cost category weight to calculate the Cost performance category score.

COST MEASURE BENCHMARKS: The Cost Measure benchmarks will be based on the data of the same performance year, i.e., benchmarks for 2019 will be based on 2019 data. If a benchmark cannot be created for a measure, that measure will not be scored.

CASE MINIMUM REQUIREMENTS: If a Cost measure does not meet the case-minimum requirement, that measure will not be scored.  

IMPROVEMENT SCORING NOT APPLICABLE: The Bipartisan Budget Act of 2018 delayed consideration of improvement in Cost until the 2024 MIPS payment year (based on the 2022 performance year data).  

REWEIGHTING TO QUALITY CATEGORY: If no Cost measures can be attributed to an eligible clinician, or they do not meet the case minimum requirement for not even one measure, the weight for the Cost category will be redistributed to the Quality performance category, making it 55%.

This concludes the summary of the proposed rule as it pertains to the Cost performance category. CMS welcomes feedback on the proposed rule till September 10, 2018. After taking the feedback into consideration, the 2019 Final Rule will be released in late Fall 2018 which will confirm if the changes proposed for the Cost category will stay as is or change.

We will focus on the proposed changes for the Promoting Interoperability category in Part IV of this series. Curious to see if the changes proposed for 2019 take us any closer to making the pipe-dream of healthcare data interoperability a reality? Follow along.

 

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