The Merit-Based Incentive Payment System (MIPS) is a performance-based payment program for clinicians who bill under Medicare Part B and meet the minimum volume threshold requirements implemented by CMS. Clinicians participating in MIPS are evaluated based on four separate categories:
- Quality: Clinicians must select and report on quality measures that evaluate care processes and patient outcomes.
- Improvement Activities: activities or programs that may improve clinical practice or care delivery, and that will likely result in improved patient outcomes. Clinicians must select at least two from a list updated annually by CMS.
- Promoting Interoperability: measures of effective electronic health record technology. The use of Certified Electronic health record technology (CEHRT) is required.
- Cost: CMS scores clinicians on multiple cost measures, based on data already submitted through the Medicare administrative claims process for an entire performance year.
Data for MIPS can be reported at the individual clinician or group practice level. CMS combines performance in each of the four categories to create a composite score to assess overall performance and determine the applicable payment adjustment. There is a two-year lag between the year for which the data are collected—the performance year--and the payment impact (i.e., quality scores collected in performance year 2018 will affect payment in 2020). See the chart below to determine the relative weighting of each category by performance year.
CMS will report on the public Physician Compare website the clinician or group's scores for each category, as well as the final score.
IDSA is aware of the lack of applicable quality measures to the ID physician and has voiced concerns to CMS regarding this troubling issue. IDSA is currently exploring initiatives to address the inappropriate evaluation of ID physicians. IDSA suggests to report on the following measures, depending on where the physician sees patients:
- Measure #110: Preventive Care and Screening Influenza Immunization
- Measure #111: Pneumococcal Vaccination Status for Older Adults
- Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
- *Measure #130: Documentation of Current Medications in the Medical Record
- Measure #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
- *Measure #407: Appropriate Treatment of Methicillin Sensitive Staphylococcus aureus (MSSA) Bacteremia
- Measure #474: Zoster (Shingles) Vaccination
- Measure #475: HIV Screening
*Indicates high-priority measures
For more details, refer to the list of recommended measures here or the explore quality-measures tool.
Clinical Practice Improvement Activities
As a part of the MIPS, CMS will also measure the use and reporting of clinical practice improvement activities, which is a new quality measurement category. Improvement activities are activities (such as expanded practice access) or programs (such as antibiotic stewardship) that may improve clinical practice or care delivery and that will likely result in improved outcomes.
Under the new MIPS program, providers can chose from a list of 90+ improvement activities (IAs) in order to meet the requirements of the improvement activity category. IDSA has prepared a list of improvement activities that ID physicians may wish to report. For the first year of the program, in order to avoid a penalty, a provider only needs to report and attest to one improvement activity. IDSA encourages physicians to review the entire list of improvement activities from the Quality Payment Program website.
Providers will need to attest that an improvement activity was performed. CMS has stated that while they’re not requiring physicians to submit any documentation to prove an AI was completed, physicians are encouraged to retain medical records or any other data used to support/determine the completion of the activity for up to 10 years following the performance period.
CMS to Study the Use and Reporting of Improvement Activities
CMS is conducting a Clinical Practice Improvement Activity study to gain a better understanding of how practices and providers will be affected by the new quality category of improvement activities. Those providers and practices who participate in the study will receive full credit for the improvement activities category in the MIPS program. To apply to participate in the study, visit the Clinical Practice Improvement Study Information website.
Example of MIPS Clinical Practice Improvement Activities
- Patient Safety and Practice Assessment: Implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions (URI Rx in children, diagnosis of pharyngitis, Bronchitis Rx in adults) according to clinical guidelines for diagnostics and therapeutics
- Expanded Practice Access: Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults, or teleaudiology pilots that assess ability to still deliver quality care to patients.
- Emergency Response and Preparedness: Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response.
- Population Management: Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; Integrate a pharmacist into the care team; and/or conduct periodic, structured medication reviews.
- Population Management: Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.
- Population Management: Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome).
CMS developed the 2017 QPP Experience Report and provided an appendix of specialty specific quality improvement activities. If you have questions or need assistance with MIPS reporting please contact the Quality Payment Program Service Center.
The help desk is available Monday – Friday; 8:00 AM–8:00 PM ET:
Phone: 1-866-288-8292 TTY: 1-877-715-6222 Email: QPP@cms.hhs.gov