T he November 2019 publication of the 2020 Physician Fee Schedule and QPP Final Rule (easer-to-read PDF format here) demonstrates how CMS continues to evolve and increase the financial impact of the Merit-based Incentive Payment System (MIPS). We highlight 10 frequently asked questions about the final changes for the 2020 MIPS performance year and what the final rule illustrates about the historical and future trajectory of the MIPS program. We provide links to our current 10 FAQs About 2019 MIPS and other sources to provide additional context and details. Please also see our recorded ABCs of the QPP webinar on the final rule.
- What are the new MIPS performance thresholds?
- How will the financial impacts of MIPS change?
- Any modifications to MIPS eligibility criteria?
- What are the new performance category weights?
- How did the Quality category change?
- How does the Cost category change?
- How does the Promoting Interoperability (PI) category change?
- How does the Improvement Activities (IA) category change?
- What are the “MIPS Value Pathways” to begin in 2021?
- How will the level of MIPS participation change?
CMS is increasing the MIPS performance threshold (PT) from 30 to 45 for the 2020 performance year. The PT separates clinicians who’ll receive penalties below the PT and those who’ll earn incentives above the PT. This continues a trend of a 15-point year-over-year increase, starting with the 2018-to-2019 transition, meant to gradually ramp towards the PT being equal to the national mean or median starting with the 2022 performance year.
The MIPS exceptional performance threshold (EPT), above which clinicians earn extra incentives, is increasing from 75 to 85, which is twice the increase seen from 2018 to 2019. CMS continues to raise the MIPS performance bar on clinicians in order to amplify the level of competition and financial impacts of the program.
This projected increase in the average incentives per clinician is driven by:
By law, the maximum MIPS penalty applied to Medicare Part B payments must be increased from a 2019 value of -7% to be -9% for 2020. The maximum penalty applies to those who score at or below a quarter of the performance threshold. On the positive side, CMS predicts that the maximum MIPS incentive for scoring 100 out of 100 MIPS points will increase from +4.69% for 2019 performance to +6.25% for 2020 performance, which continues a trend of increasing possible incentives seen since 2018 based on actuals and CMS predictions.
Note: The 2019 and 2020 CMS predictions are from the 2019 QPP
Final Rule and 2020 QPP Final Rule, respectively
As an example, a 100-clinician organization with $10M of annual Medicare Part B payments could earn nearly $600k for achieving the maximum MIPS score.
This projected increase in the average incentives per clinician is driven by:
- the raising of the two performance thresholds PT and EPT,
- the mandated increase in the base incentive multiplication factor (from 7 to 9),
- the increase in the penalties applied to low performers which are shifted to incentives for high performers, and
- the reduction in the number of clinicians sharing in the incentives due to the higher thresholds.
Here’s a diagram from the proposed rule illustrating CMS’ prediction for how the Part B payment adjustment would vary as a function of the MIPS score for 2020:
2020 Physician Fee Schedule and QPP Final Rule, Figure 1, p1547.
3. Any modifications to MIPS eligibility criteria?
The eligible clinician types, exclusions, and opt-in option remain the same for 2020 as in 2019. There are no proposed changes to the MIPS eligibility criteria.
4. What are the new performance category weights?
There are no changes to the MIPS category weights for the 2020 performance year:
|Category||2019 Weights||2020 Weights||Maximum 2020 Points|
|Promoting Interoperability (PI)||25%||25%||25|
|Improvement Activities (IA)||15%||15%||15|
|Complex Patient Bonus||5|
CMS maintained the Cost category weight, rather than increasing it, to allow clinicians more time to adapt to new and revised Cost measures. There are modifications to the category reweighting rules (e.g. if a clinician is excluded from a category, that category’s weight is redistributed to another category), as illustrated in Table 55 of the 2020 QPP Final Rule. The reweighting rules can impact the relative importance of different MIPS categories to a clinician and, thereby, the amount of relative attention that clinician should pay to each category.
For clinicians, there are no major systemic changes to the Quality performance category. Interestingly, CMS emphasizes that “cherry picking” data to misrepresent true performance will be subject to audit and modified payment adjustments. In keeping with CMS’ Meaningful Measures framework, 42 quality measures were eliminated, while only 4 new measures were added.
CMS cites more stringent requirements for the Quality Registry quality data collection type as being among the three most significant changes to MIPS, along with the expansion of the Cost category and the potential introduction of MIPS Value Pathways in 2021. See page 1570 of the final rule or CMS’ 2020 QPP Final Rule Fact Sheet for more details.
6. How does the Cost category change?
Of the four MIPS performance categories, the Cost category changes the most. The patient attribution logic of the two population-based measures (Total Per Capita Cost and Medicare Spending Per Beneficiary) is completely overhauled (see pages starting 1316 and 1333, respectively, of the final rule). CMS is remedying a common issue with these two measures whereby certain clinicians, such as of particular specialties, are attributed patients over whom they have insufficient control and influence to impact the cost outcomes gauged by those measures. Consequently, these changes in the attribution methodologies could have a dramatic impact on the cost measure values for some clinicians as compared to past years.
In addition, the final rule introduces 10 new episode-based cost measures, increasing the total number of such measures to 18:
2020 Physician Fee Schedule and QPP Final Rule, Table 44, p1296.
CMS will introduce additional episode-based cost measures in future years to support the MIPS Value Pathways by aligning with quality measures and to meet the MACRA requirement that at least half of all Part A and Part B national costs must ultimately be monitored by the set of episode-based cost measures.
Healthcare organizations can gain early insight into MIPS Cost category performance and identify improvement levers by analyzing available data from CMS, such as CMS field-based testing reports for episode-based cost measures and MIPS performance feedback reports
7. How does the Promoting Interoperability (PI) category change?
CMS drastically changed the PI category for 2019 as compared to 2018. In contrast, the 2020 final rule keeps the PI category largely the same for 2020 except for the following changes, including two which are retroactively applied to the 2019 performance year as well:
- require a yes/no response rather than a number of prescriptions for the optional bonus measure “Query of Prescription Drug Monitoring Program (PDMP)” – this reduces the burden on clinicians and EHR vendors to track the exact number of queries (also applies to 2019);
- change the required measure “Support Electronic Referral Loops by Sending Health Information” to redistribute its 20 points to the “Provide Patients Electronic Access to Their Health Information” measure in the event that the clinician earns an exclusion from the first measure (also applies to 2019);
- remove the “Verify Opioid Treatment Agreement” measure; and
- change the definition of a hospital-based group (as identified by tax ID) eligible for an exclusion from the PI category to be more than 75%, rather than 100%, of the MIPS eligible clinicians in the group being hospital-based.
8. How does the Improvement Activities (IA) category change?
As with the Quality category, the Final Rule includes a net reduction in the number of measures in the IA category, as there are 15 IA activities removed, 2 added, and 7 modified. However, the more significant change for IA is the requirement that group reporters (sharing a tax ID) must have at least 50% of clinicians satisfying an IA activity, each clinician within any 90-day reporting period, in order for the group to earn points for that activity. Currently, many multispecialty groups are below the 50% threshold for past reported IA activities, such as telehealth and depression screening, and thereby need to re-evaluate their IA decisions and approaches for 2020.
9. What are the “MIPS Value Pathways” to begin in 2021?
The MIPS Value Pathways or “MVPs” represent a proposed re-design of the MIPS program slated for 2021 wherein combinations of measures across the MIPS performance categories would be required for particular types of specialties and medical conditions. For instance, CMS describes an example for Diabetes Prevention and Treatment whereby 3 Quality measures, 3 Improvement Activities, and 2 Cost measures would be mandated for, say, all endocrinologists. The same Promoting Interoperability measures and common set of claims-based population health measures would be mandated for all MVPs.
The primary goals of MVPs are to reduce reporting burden while more closely aligning measures with clinician workflows and enabling better performance comparisons across clinicians for consumers to leverage. CMS anticipates there would be a phased roll out of the re-design, perhaps beginning with certain specialties and expanding to others in later years.
10. How will the level of MIPS participation change?
In light of the proposed changes to the program, CMS predicts that the number of MIPS eligible clinicians will rise by about 13% to reach 880,000 clinicians, while the percentage of clinicians who will fall below the raised performance threshold and thereby be penalized will remain steady at about 9%. However, given the increased rigor of the program relative to past years, clinicians and groups will need to work harder to stay above the higher performance threshold and exceptional performance thresholds..