A couple of weeks ago, the Centers for Medicare & Medicaid Services (CMS) released an important report that provides insight into a significant contributor of clinicians’ overall Medicare reimbursement for this year. Specifically, CMS provided the public with access to raw data and released a summary of clinicians’ performance in the Quality Payment Program (QPP) in 2022. There are two tracks in the QPP: participation in the Merit-based Incentive Payment System (MIPS) or participation in an advanced alternative payment model (Advanced APM). Under both options, a clinician’s performance in 2022 affects the Medicare reimbursement they are receiving this calendar year (2024).

There has been a lot of regulatory and legislative attention on MIPS and the Advanced APM bonus. On the legislative side, Congress recently extended the bonus that clinicians can receive for participating in an Advanced APM for performance year 2024 (payment year 2026) in the Consolidated Appropriations Act, 2024. However, Congress needs to act again in order for that bonus to continue. There has also been interest in reforming both MIPS and the Advanced APM bonus to provide better incentives to improve quality of care and reduce costs. The Senate Finance Committee released a white paper last week that lays out a series of questions about how to restructure the QPP. The white paper even states that the Finance Committee is “considering repealing or scaling back the MIPS program to relieve physicians’ administrative burden and alleviate churn from A-APMs (Advanced APMs) back to MIPS.” The deadline to submit comments on the white paper is June 14, 2024. On the regulatory side, CMS keeps making changes to the QPP year after year in the annual physician fee schedule (PFS) rule. Many of these changes are designed to ratchet up the requirements as clinicians gain more experience in MIPS, making it more difficult for clinicians to obtain a bonus and avoid a penalty.

It is important to view this 2022 QPP report with this legislative and regulatory landscape in mind. As I mentioned in a Regs & Eggs blog post from August 2023, the 2022 performance year was the first year during which clinicians who performed well actually obtained a sizable bonus. While a perfect score in previous years only yielded a 1% – 2% bonus, the same score in 2022 led to an 8.26% payment bump in 2024.

In the previous blog post, I provided some possible reasons for why the maximum bonus was so much higher than previous years. I was also interested in knowing exactly who was getting the 8.26% bonus, but couldn’t draw any conclusions since the performance data were not yet available. Now we have the data!

The 2022 QPP experience report tells an interesting story. Overall, there was a big drop of 11% in the number of clinicians who were eligible to report in MIPS – meaning that many more clinicians qualified for the APM bonus and did not have to report in MIPS. (Between 2021 and 2022, there was a 26% increase in Advanced APM participation.) The same percentage (5.9%) of MIPS-eligible clinicians did not report, due to extreme and uncontrollable circumstances, exception applications, special status or clinician type. The mean final score for all MIPS-eligible clinicians was 82.90 points, and the median final score was 85.29 points, both of which were lower than the 2021 mean and median scores. Since the performance thresholds increased from 60 points in 2021 to 75 points in 2022, those who were able to surpass the threshold achieved higher bonus amounts.

One of the big changes in 2022 was that CMS was able to score the Cost category of MIPS for the first time in a while – and that category contributed 30% of clinicians’ overall score. The two top cost measures in MIPS are the Total Per-Capita Cost Measure (TPCC) and the Medicare Spending Per Beneficiary Measure (MSPB). More than 90% of clinicians were scored on the TPCC measure and approximately 73% received a score on the MSPB measure. The mean and median scores for both of these cost measures and for the other episode-based cost measures were the lowest mean and median scores of any performance category. Luckily, though, only 43% of MIPS-eligible clinicians received a cost performance category. Approximately 57% of MIPS-eligible clinicians didn’t receive a cost performance score because (1) they didn’t meet the requirements for any cost measure, (2) they were approved for reweighting due to extreme and uncontrollable circumstances, or (3) they reported through the APM Performance Pathway (cost isn’t scored under this MIPS reporting option).

Answering my previous question of who achieved the top score, I was surprised to see that practices of all sizes were able to attain the perfect score and get an 8.26% bonus – even solo practitioners and clinicians in rural areas. However, on average, smaller practices had lower overall scores (and corresponding payment adjustments) than larger practices. This pattern makes sense, since larger practices have more resources that they can invest in quality reporting, and more smaller groups are not reporting any data, thereby bringing down their mean and median scores.

Mean Payment Adjustments

Solo practitioner: -1.89%

Small practice (2 – 15 clinicians): 1.40%

Medium practice (16 – 99 clinicians): 1.74%

Large practice (100+ clinicians): 2.43%

There are many more insights one can glean from reviewing the report and analyzing the raw data, but here are my overall takeaways for what this all could mean going forward:

• Small groups can be perfect. It is possible! Yes, solo practitioners and small groups were able to achieve a perfect score! And, if you exclude those solo practitioners and small groups who simply didn’t report, the mean and median payment adjustment for these clinicians was actually around 1-3%. Thus, if solo and small groups do actually report data, they can fare well. However, they may need additional resources and assistance to do so—which may not be readily available.
• Will poor performance in the Cost category cause more clinicians to receive a penalty? Although the majority of clinicians were exempted from the Cost category in 2022, those who were subject to this category did not perform well. As I have argued previously, the Cost category is like a black box for many clinicians, as it is very difficult for them to predict their score, understand their performance and improve upon it. If more clinicians become subject to the Cost category (which, again, represents 30% of the total MIPS score), and transparency around the cost measures does not improve, we may start seeing lower overall mean and median scores in future years.
• There was more APM participation, but… The number of clinicians participating in Advanced APMs grew significantly. However, the 2022 performance period (2024 payment year) was the last year when the full 5% payment bonus was available. The bonuses are smaller (3.5% in the 2025 payment year and 1.88% in the 2026 payment year). Going forward, without congressional action, there won’t be a separate bonus in 2027 – only a slightly higher conversion factor update under the Medicare PFS.
• Going forward, will the MIPS financial incentives be larger than those available through an Advanced APM? The MIPS maximum bonus of 8.26% may just be a fluke or it may be an indication that we will see larger MIPS bonuses going forward. Even though the goal of the Medicare Access and CHIP Reauthorization (MACRA) was to encourage clinicians to transition from MIPS to APMs, the financial incentive available in MIPS may in fact be greater. Even CMS is worried about this situation, expressing concern in the CY 2023 PFS proposed reg that MIPS eligible clinicians may actually receive a higher overall payment under the PFS than those who participate in Advanced APMs.

I want to end by noting that there is a lot of uncertainty about the size of the MIPS bonuses and the status of the Advanced APM bonus going forward. With the increase in cybersecurity attacks, some clinicians will not have access to the data they need to report in MIPS. CMS has opened the application for claiming an exemption from MIPS in 2024 due to extreme and uncontrollable circumstances, and being impacted by the recent Change Healthcare and Ascension cybersecurity attacks is a valid reason for requesting the exemption. Fewer clinicians reporting in MIPS could affect the maximum size of the bonus.

Further, as stated above, there is congressional interest in reforming MIPS and the Advanced APM bonus. While the chance of any meaningful reform this year (2024) is limited, there will be ample opportunities for interested parties to express their views on the QPP in the next few months. However, it will be important for Congress to take this report into consideration as it makes policy decisions. The Senate Finance Committee’s white paper did not include data from the report and thus did not mention the large maximum MIPS bonus in 2022 and how that affects the relative incentive going forward of participating in MIPS versus an Advanced APM. In fact, the Senate Finance Committee, citing data from 2021, states that the “largest MIPS bonus has amounted to 2.34 percent, making participation in A-APMs (Advanced APMs) more financially attractive to providers.” We know now that the opposite may be true!

Finally, on the regulatory front, we are entering PFS rulemaking season, during which CMS will soon be establishing policies for the QPP in 2025. CMS had previously proposed (but did not finalize) an increase to the MIPS performance threshold in 2024, and therefore may likely propose one for 2025. CMS could also introduce new measures, more stringent Quality, Cost, Improvement Activities, and Promoting Interoperability performance category requirements, and changes to the MIPS Value Pathways (MVPs) and APM Performance Pathway reporting options, all of which could impact the projected size of the MIPS bonus and the likelihood that the majority of clinicians will still be able to avoid a penalty. CMS also has the stated goal of sunsetting MIPS and fully transitioning to MVPs, so we will see if CMS actually proposes a date for doing so in this year’s reg as well. All in all, we are close to finding out what CMS’s proposed plan is for the QPP in the future, so stay tuned!

Until next week, this is Jeffrey saying, enjoy reading regs with your eggs.

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