Monitoring MIPS: The Driving Forces for Participation

2018-04-12T09:41:33+00:00 November 1st, 2017|

Monitoring MIPS: The Driving Forces for Participation

As I highlighted in my recent post covering this topic, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will further move from paying Medicare health professionals for volume to paying them for value through the Quality Payment Program (QPP) set forth by MACRA. The Merit-Based Incentive Payment System (MIPS) is the default path that will apply to almost all providers. The new rule, published by the Centers for Medicare & Medicaid Services (CMS) in May 2016, paves the way for new healthcare performance measurements. Participation is no longer enough; rather, it’s about how you compare to your peers. And one thing is certain: Medicare payment reform will put your practice at a crossroads related to quality measurement and reporting.

In Part II of this series, I want you to consider some of the driving forces outlined below. When you do, you may determine that your full participation in MIPS can wait, and simply testing the quality program for now may be your best avenue. This is especially true if you’ve not established your own perspective on clinical quality.

Medicare as a Percent of Net Revenue

Look at your payer mix. Assess what percent of your entire net revenue reflects Medicare. For instance: Let’s say 50 percent of your patient volume represents Medicare, but that volume translates into just 20 percent of revenue; whereas the other 50 percent of your patient volume represents commercial payers, which translates into 80 percent of revenue.

Now consider the cost associated with participating in quality reporting through a Qualified Clinical Data Repository (QCDR) to help your practice with quality-based care metrics. If that cost reflects more than two years of impacted Medicare Revenue, acting now may not be in your best financial interest. Perhaps focusing your efforts in monitoring and delivering high-quality measures in support of MIPS may be more impactful for you at this point in time. Remember, simple participation is no longer the standard – it’s how you perform.

With 4,000-plus comments about the ruling and talk about potential implementation delays, the government continues to refine how to reimburse clinicians – as referenced above with the four value-based options of MACRA. Moreover, the government will not shape how your commercial plans will reimburse. As you and your clinical leadership leave the next conference with hands wringing, remember that most commercial payers will continue to base provider reimbursement on existing procedure codes. So understanding exactly how governmental-driven quality directives stand to impact overall revenue for your practice is key.

Employed, Independent Physicians or Hospital-Based Specialties

Hospital-employed physicians who are salaried will not carry a direct burden related to MIPS – the hospital will. As the first step, it may be important to evaluate the contract terms of employed physicians to address alignment with quality and reimbursement directly tied to their clinical delivery. If their behaviors don’t support quality reporting – and more importantly high quality performance – you may ask yourself, “Why make the investment in supporting capabilities for reporting in the first place?”

Conversely, many hospital-based specialties (specifically anesthesiology and emergency medicine) include subsidies paid by the hospital in the form of margin or revenue guarantees. In these instances, such clinician practices may have little incentive to make the process and technology investments needed for reporting (data capture tools, training, QCDR, etc.) because the reimbursement burden is borne by the hospital. Depending on which side of the coin you’re on – the hospital or the clinical practice – your subsidy arrangement could be a critical evaluative element. Independent physicians may actually benefit by evaluating their Medicare population’s revenue impact to see if they may continue with quality reporting and keep a watchful eye on what’s going on with the quality measures that MIPS dictates. Alternatively, independent physicians can isolate a mechanism – such as an electronic health record (EHR) – that will capture quality measures for care provided. Paper documentation is fine, but define a clear process for keying data into a database to manage reporting and start educating your team.

Group Size

An average practice with 30 physicians simply may not have the surplus funds to invest in quality reporting tools like a QCDR infrastructure. At a minimum, their focus will be to invest in an EHR to collect and report on quality data related to patient care. Many will monitor reporting and consider piloting for reporting to a QCDR, if at all possible. Among the comments that CMS has received about MACRA, many referred to addressing the complexity and burdens that the rule will present to small practices. Forty percent of respondents in a recent survey of physicians working in groups of fewer than 25 doctors anticipate the new requirements will lead to an “exodus” of small practices from Medicare, as they suffer “death by bureaucratic strangulation.”1

Clinical Quality Measurement as a Competency

Historically, the concept of “value-based care” has meant different things to physicians than it does to patients, insurance companies, policy makers, etc. MACRA has defined it for everyone in this instance, having by identifying five quality domains (i.e., clinical care; safety; care coordination; patient and caregiver experience; population health and prevention) for measurements developed under the CMS Quality Measure Development Plan, which align with the National Quality Strategy and the CMS Quality Strategy.2

Importantly, make time now to discuss quality in your care setting. How is clinical quality a differentiator for your practice? Many practices market quality as something that sets them apart, but in reality have little tangible proof of such claims. To support what’s meaningful to your patients and your practice, begin to track, measure and report on quality performance metrics. Your practice will benefit from a personalized approach that demonstrates how you can put quality into action when treating your patients, and how you can better integrate quality processes into your organization. Form a consensus on quality among your clinicians before ever making strategic financial decisions or investing in reporting capabilities to support clinical quality metrics for MIPS. If you place your focus on what matters most to your clinical team and your overall practice, you’ll be ready to act and demonstrate quality once the final MIPS methodology is final and released.

Act Now or Wait and See?

Only you can make an informed decision about your future and the way you care for your patients. The basic takeaway here is that every practice will react differently to the implications of MIPS. Do not expect to see or follow a one-size-fits-all roadmap to prepare for MIPS – and be leery of the fear-mongering sales pitch, as the impact to your organization may be very different than that of another. Depending on your practice size, your specialty and your clinical perspective on patient care and quality, you may explore more than one approach before selecting the one that best prepares you for value-based care and MACRA this year and beyond.


  1. Medscape Medical News. Many Physicians Predict Mass Exodus from Medicare over MACRA.
  2. The Centers for Medicare & Medicaid Services. CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System and Alternative Payment Models.

About the Author

Rob Hager

Rob Hager

Vice President, Physician Services Client Operations

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As Vice President of Physician Services Client Operations, Rob Hager is responsible for Conifer Health's relationship with Tenet Healthcare from a physician services standpoint, including revenue cycle support, operations and client delivery. His expertise in performance improvement consulting and operational acumen has helped diverse organizations transform their operations by leveraging technology, people and process alignment with sound business principles. Prior to joining Conifer Health, Rob was Chief Revenue Officer at NorthStar Anesthesia and Senior Vice President for Revenue Cycle Operations at the Schumacher Group, and has held healthcare leadership positions at Deloitte Consulting, Cap Gemini Ernst & Young and Arthur Andersen.

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