Running Head: MIPS System 1

Merit-Based Incentive Payment System (MIPS)

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Merit-Based Incentive Payment System (MIPS)

Introduction

Public health is prioritized in the United States to ensure that the well-being of the

citizens is improved. The federal government has placed many initiatives like the Medicare and

Medicaid insurance plans to cushion the population against health-related implications that arise

due to lack of enough funds to access medical treatment. This paper focuses on the recently

introduced Merit-Based Incentive Payment System (MIPS) intended to improve the quality of

healthcare. The paper goes on to identify the background of the initiative, measurement

categories, eligibility criteria, expected and actual outcomes, and also highlights the concern

about the future of the MIPS system.

General Background of MIPS

The MIPS was created through the Medicare program and the CHIP Reauthorization Act

2015 (MACRA). This initiative was launched on 1st January 2017 to influence healthcare

transformation to a pay-for-value system from the old fee-for-service system. “The MIPS

program established three value reporting and quality plans namely Meaningful Use, Physical

Quality Reporting System, and Value-based Payment Modifier (MU, PQRS, and VBM) and

compiled them into a single program (AMA, 2021)”. The program is one of the best initiatives

put in place to improve the Quality Payment Program which focuses on moving the Part B

Medicare providers to a program that is performance-based in regards to the payment system.

According to the programs, all those providers under the Part B Medicare plan who meet the

eligibility criteria must be involved in MIPS or be subjected to a 7% reduction of payment

adjustment on the reimbursements of the Medicare Part B plan (AMA, 2021).

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Eligibility Criteria

The unique element of the MIPS program is that providers have the opportunity of

choosing to participate as part of a group or as individuals. “For the individual clinicians who

meet the eligibility criteria, they need to report the information to Centers for CMS under a

National Provider Identifier Standard (NPI) that is pegged to one Taxpayer Identification

Number (TIN)” (AMA, 2021). For more than one clinician that has separate NPIs and has

replaced their billing rights to one TIN, also have the opportunity of participating in the MIPS as

a single group. The clinicians who take part in the MIPS programs as a single group undergo an

assessment as a single unit regarding the four MIPS categories of performance.

MIPS’ Measurement Categories

Medicare is tracked by the MIPS system and measured by the four available performance

categories. These measurement categories include cost, quality, improvement, and promotion of

interoperability. Medical specialists should report six measures under the quality measurement.

The family physicians need to select the appropriate measures that are aligned to their practice

since most of them participate in the MIPS. “The six available quality measures are Electronic

Clinical Quality Measures (eCQMs), MIPS Clinical Quality Measures (CQMs), Qualified

Clinical Data Registry (QCDR) measures, Medicare Part B claims measures, CMS web interface

measures and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for

MIPS survey” (QPP, 2020).

eCQMs are important measurement tools that quantify and help in tracking healthcare

quality and ensure that the healthcare system is efficient in delivering safe, equitable, patient-

centered, and timely care. The system electronically extracts data from the EHR system and uses
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it to provide the measurement of the provided healthcare to the public. Conversely, the CQMs

measure the processes, patient care outcomes, experiences, and observe the related treatments to

singe or more aims of quality healthcare like timely care, efficiency, and effectiveness.

Moreover, QCDR acts as a forum that does the collection of clinical and medical data to help in

disease and patient tracking to be used in the improvement of the provided care. Also, the CMS

web interface provides virtual measuring points for groups consisting of at least 25 clinicians as

they submit their quality data to benefit from the wide array of measures. Finally, the CAHPS

provides a survey program for MIPS whereby clinicians are involved with the survey group to

measure patient experience through composite measures and rating measures.

Key Elements of Implementing MIPS

Ten steps have been identified for the successful implementation of the MIPS initiative

(AMA, 2021). The initiative is intended for eligible clinics who are not currently active in the

APM but wishes to participate in MIPS. The following action plan helps the clinicians in

planning on how to participate in the MIPS program. The first step is to identify if a clinician is

eligible for the program like those that offer Medicare services for their patients. After clinicians

have determined their legibility, they should review the performance categories that are available

under the program. MIPS calculates the overall score to help in determining the categories that

have the measures relevant to a clinician. The categories of performance are improvement

activities (IA), promoting interoperability (PI), quality, and cost. The next step is to plan for the

MIPS participation to ensure that the clinicians evade the 7% penalty charged for not

participating. As a clinician proceeds into the program, it is essential to review the performance

of past MIPS performance to influence future improvements.

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Thereafter, the participating clinicians can decide to report their data as a group or

individual and this decision should be done with a strategic focus. The next step is for the

clinicians to chose their reporting mechanisms that will be crucial during the measuring process.

“The available reporting mechanism includes qualified registries, CMS web interface, QCDRs,

EHR and claim based reporting” (CMS, 2021). Thereafter, for the participants who are reporting

through the PI category, they have to conduct a security risk analysis to provide the required PI

measure. Moreover, it is a requirement that participants who are under IA or PI to do their

reporting for approximately 90 days and a whole calendar year for those reporting under quality.

The next step requires the participants to conclude the MIPS performance by ensuring that they

have complied with the criteria on data completeness for the selected category. Finally, the MIPS

data should be submitted through the chosen vendor on the CMS system to ensure compliance

with the due date that applies to the specific category.

Expected Outcomes of MIPS

In the previous calendar years, CMS completed its quest to refit MIPS through the

implementation of MIPS Value Pathways (MVPs) to regroup the measures from improvement

activities and quality categories with regards to medical specialty or conditions. MVPs are

planned to be implemented in 2021 (Advisory Board, 2020). This initiative is expected to bring

relief to many clinicians since CMS has postponed the MVPs implementation to 2022. “It is

expected that CMS will sunset the use of the CMS web interface in reporting by 2021” (CMS,

2021). The ACO reporting has been using the interface to conduct data reporting activities. With

the plan to eliminate the APM scoring standard and relacing with APM Performance Pathway

(APP), the measures are expected to be fixed for each of the categories of performance.
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Clinicians and other MIPS providers expect a significant contribution from the new

payment system program. With the quality category replacing the initial PQRS program,

providers will record data as a group or individuals and they pick to report to the best that

represents their specialty. Nevertheless, “the PI category is expected to promote patient

engagement and the exchange of health information electronically through certified electronic

health record technology (CEHRT)” (CMS, 2021). Also, the IA is expected to improve

population management, expand access to practice, and achieve health equality since it allows

participants to report activities that cause improvement to the clinical operations.

Furthermore, the initiative is expected to provide a patient-centered healthcare system.

This is expected to hinge the provisions that enable patients to get the health information

exchange through available healthcare technologies and systems. MIPS is expected to promote

interoperability whereby patients will easily access their medical information as a requirement

through the APIs. Also, the MIPS program advances the plight for medical reforms which will

reward the healthcare providers who are implementing the recommended strategy reforms

(Heath, 2016). This will further improve the provision of healthcare to patients and therefore

improving the wellbeing of the public health in the United States.

Actual Outcomes of MIPS to Providers

CMS has managed to create a discrete list indicating the goals of the MIPS program that

providers have to achieve to remain compliant. According to Squitieri & Chung (2017), MIPS

has provided the participants with a wide range of goals based on high-prevalent medical

conditions, cost of medication and so they can easily select the value goals that influence them to

improve their delivery for the intention of caring for the healthcare needs of the population. This

program has facilitated the exclusion of high thresholds that must be met and therefore helps in
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solving the comparative problems involved in scoring since providers can strive on a similar

category basis.

Besides, the reporting burden has also been reduced significantly through the improved

use of claims information (Berdahl, Easterlin, Ryan, Needleman, & Nuckols, 2019). For the

providers, regardless of their size, they feel satisfied since they understand that their participation

in the program is correlated to the success of MIPS. They manage to improve the quality of their

services while simultaneously reduce their spending on health-related requirements. Therefore,

providers are more likely to participate in the program due to the related motivation. Wilk & Jain

(2019) asserts that when these providers participate in the program, they achieve a greater score

which translates to a better potential that can put them in a meaningful position for financial

reward.

Actual Outcomes of MIPS to Patients

The MIPS program has managed to improve service delivery to vulnerable patients

through collaboration with Medicare treatment insurance plans (Eggleton, Liaw, & Bazemore,

2017). The program has helped in simplifying the medical requirements and therefore making

healthcare access less burdensome to patients. This development has also been promoted by the

improvement in communication between the participants and the administration. Moreover,

MIPS has enabled doctors to access special technological equipment required for patient care

like retinal screening equipment for eye care (Berdahl, Easterlin, Ryan, Needleman, & Nuckols,

2019). This accessibility has improved the well-being of patients that need special medical

attention. Initially, it was a great challenge for patients to access eye care examination and

treatment from two different healthcare providers. Besides, the access to medical information of

patients is improved by MIPS program through the interrelated healthcare systems (Nichols,
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2017). Therefore, this has improved the treatment of patients since reliable information

concerning the medical history of patients is readily accessible.

The Future of MIPS

The Quality Payment System has been improved since it was launched in 2017.

Incremental steps have been put in place to ensure that the programs like MIPS and APM

provide the best solution in tracking medically related information and acknowledge the different

variables that are within the operations of clinicians. There is a need to further develop these

programs especially the MIPS to ensure that there is a reduced burden during reporting, enhance

stakeholder feedback, and further refine the program requirements (Jones, Raphaelson, Becker,

Kaloides, & Scharf, 2016). Therefore, the future of this program must be assessed to identify

factors that can derail its focus so for immediate rectification. In this regard, the main question is

whether the MIPS program will offer improved outcomes in the future or will fail to meet the

intended objectives.

The clinicians and other providers have continuously asserted that the program has

remained to be complex in helping them in achieving the required healthcare services. Most of

the factors that make the program complex have been identified and some of them are currently

being addressed. For instance, in the last few years, patients have received leverage through the

Patients over Paperwork program of reviewing MIPS. This initiative has assisted in eliminating

the unwanted elements of the system and streamlining program requirements thereby reducing

the burden imposed on clinicians. The objective of streamlining these requirements is to progress

away from the insufficient reports that are received from activities and measures, to realize better

types of measure sets that offer more meaningful information to the providers and the general

public.
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Conclusion

Since the inception of MIPS in 2017, the program has enabled service providers and most

importantly, special caregivers like clinicians to offer better healthcare service in the US.

Through the collaboration with the Medicare plan, the program has tremendously improved the

wellbeing of the public. Nevertheless, the initiative is still in its early stages and therefore it faces

several challenges which the agencies have responded to amicably. The future remains uncertain,

and the big question regarding this initiative is whether it will pass the test of time. More studies

should be done to identify the factors that might affect the focus of the initiative to ensure that

the future goals of MIPS are realized.

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References

Advisory Board. (2020, August 5). The 2021 Quality Payment Program proposal: The 3 key

updates to know. Retrieved March 9, 2021, from www.advisory.com website:

https://www.advisory.com/daily-briefing/2020/08/05/qpp

AMA. (2021). MIPS Action Plan. Retrieved March 9, 2021, from American Medical Association

website: https://www.ama-assn.org/system/files/2019-05/2019-mips-action-plan.pdf

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

CMS. (2021). Merit-based Incentive Payment System (MIPS) Overview - QPP. Retrieved from

Cms.gov website: https://qpp.cms.gov/mips/overview

Eggleton, K., Liaw, W., & Bazemore, A. (2017). Impact of Gaps in Merit-Based Incentive

Payment System Measures on Marginalized Populations. The Annals of Family Medicine,

15(3), 255–257. https://doi.org/10.1370/afm.2075

Heath, S. (2016, April 28). How MACRA, MIPS will Help Deliver Patient-Centered Care.

Retrieved March 9, 2021, from PatientEngagementHIT website:

https://patientengagementhit.com/news/how-macra-mips-will-help-deliver-patient-

centered-care#:~:text=MIPS%20will%20%E2%80%9Cemphasize%20interoperability

%2C%20information
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Jones, L. K., Raphaelson, M., Becker, A., Kaloides, A., & Scharf, E. (2016). MACRA and the

future of value-based care. Neurology: Clinical Practice, 6(5), 459–465.

https://doi.org/10.1212/CPJ.0000000000000296

Nichols, J. (2017). Knowing Quality When You See It. Caring for the Ages, 18(7), 4–5.

https://doi.org/10.1016/j.carage.2017.06.005

QPP. (2020). Quality Measures Requirements - QPP. Retrieved from qpp.cms.gov website:

https://qpp.cms.gov/mips/quality-measures?py=2020

Squitieri, L., & Chung, K. C. (2017). Measuring Provider Performance for Physicians

Participating in the Merit-Based Incentive Payment System. Plastic and Reconstructive

Surgery, 140(1), 217e226e. https://doi.org/10.1097/prs.0000000000003430

Wilk, A. S., & Jain, S. (2019). Effective Population Health Care Delivery Under Medicare’s

Merit-based Incentive Payment System: Realigning Accountability With Capability.

AJMC. Retrieved from https://www.ajmc.com/view/effective-population-health-care-

delivery-under-medicarersquos-meritbased-incentive-payment-system-realigning-

accountability-with-capability