Ordinarily, CMS will calculate the MIPS final score for a practice group’s physicians on an individual or group basis.[1] However, physicians participating in a “MIPS APM” are subject to a significantly different scoring methodology – the “APM scoring standard.” This article: (1) outlines CMS’s “snapshot” process for determining which physicians CMS will score using the APM scoring standard; and (2) summarizes how CMS will apply the APM scoring standard for each of the current MIPS APMs.
CMS’s “Snapshot” Dates and the APM Scoring Standard
CMS will use the APM scoring standard, which is substantially different from the ordinary MIPS scoring methodologies, to calculate the MIPS final score for a practice group’s physicians who, on at least one of three “snapshot” dates during a MIPS performance year (March 31, June 30 or August 31), were participating in an alternative payment model designated by CMS to be a “MIPS APM.”[2] The APM scoring standard applies to these physicians for the performance year even if they leave the MIPS APM later in the year. The current list of MIPS APMs follows.
- Medicare Shared Savings Program (ACOs in Tracks 1, 2 or 3)
- Next Generation ACO Model
- Comprehensive Primary Care Plus (“CPC+”) Model
- Oncology Care Model (one-sided risk and two-sided risk arrangements)
- Comprehensive ESRD Care Model (LDOs and non-LDOs with one-sided or two-sided risk arrangements)
In sum, a practice group’s physicians who were participating in one of these MIPS APMs on March 31, 2017 will have their 2017 MIPS final score calculated pursuant to the APM scoring standard. Similarly, a practice group’s physicians who were not participating in one of these MIPS APMs as of March 31, 2017 will have their 2017 MIPS final score calculated using the APM scoring standard if they are participating in one of the MIPS APMs as of June 30 or August 31 of this year.
Opportunities and Challenges Under the APM Scoring Standard
Under the APM scoring standard, the MIPS final score attributed to a practice group’s physicians can be affected, positively or negatively, by the performance of physicians who are not members of that same practice group (who may perform better or worse than the physicians in that same practice group). Participation in a MIPS APM, and the accompanying application of the APM scoring standard, could, for many practice groups, result in the group’s physicians receiving a MIPS final score higher than what they would have otherwise received. On the other hand, for practice groups whose physicians would achieve a high MIPS final score under the ordinary MIPS scoring methodologies, participation in a MIPS APM, and the resulting application of the APM scoring standard, could result in the physicians receiving a MIPS final score lower than what they would have received if they had not participated in the MIPS APM. The tables below summarize the application of the APM scoring standard, for the 2017 MIPS performance year, for each of the MIPS APMs listed earlier in this article.
| 2017 MIPS Performance Categories and Scoring Weights | Medicare Shared Savings Program (“MSSP”) |
|---|---|
| Quality (scoring weight: 50 percent) |
The MSSP ACO (Tracks 1, 2 and 3) submits its MSSP quality measures to CMS as usual, using the CMS Web Interface and the same process and measures it normally uses to report quality measures for the MSSP. The measures are submitted only once but are used for both the MSSP and the MIPS quality reporting and scoring. Because the quality measures submitted for the MSSP are also MIPS quality measures, CMS will use the MSSP quality measures reported through the CMS Web Interface to calculate, based on MIPS quality performance category requirements and benchmarks, a single MIPS quality performance category score that will be applied to each physician and other MIPS eligible clinicians participating in the ACO (as identified on the ACO’s Participation List on March 31, June 30 and/or August 31 of the performance year). The MSSP quality performance data not submitted via the CMS Web Interface (i.e., the CAHPS survey and claims-based measures) are not included in the MIPS quality performance category score. |
| Cost (scoring weight: 0 percent) |
Not applicable. |
| Advancing Care Information (scoring weight: 30 percent) |
Each practice group that serves as an ACO participant in a MSSP ACO submits its own advancing care information performance category measures according to the ordinary MIPS group reporting process. All individual practice group scores will be aggregated as a weighted average, based on the number of physicians and other MIPS eligible clinicians in each practice group, to produce a single MIPS advancing care information performance category score that will be applied to each physician and other MIPS eligible clinicians participating in the ACO (as identified on the ACO’s Participation List on March 31, June 30 and/or August 31 of the performance year). |
| Improvement Activities (scoring weight: 20 percent) |
Each physician and other MIPS eligible clinicians participating in a MSSP ACO (as identified on the ACO’s Participation List on March 31, June 30, and/or August 31 of the performance year) will automatically receive the maximum score of 40 points in the MIPS improvement activities performance category and will not need to report additional improvement activity information for MIPS. |
| 2017 MIPS Performance Categories and Scoring Weights | Next Generation ACO Model (“NGAM”) |
|---|---|
| Quality (scoring weight: 50 percent) |
The NGAM ACO submits its NGAM quality measures to CMS as usual, using the CMS Web Interface and the same process and measures that it normally uses to report its quality measures for the NGAM. The measures are submitted only once but are used for both the NGAM and the MIPS quality reporting and scoring. Because the quality measures submitted for the NGAM are also MIPS quality measures, the NGAM quality measures reported through the CMS Web Interface will be used by CMS to calculate, based on MIPS quality performance category requirements and benchmarks, a single MIPS quality performance category score that will be applied to each physician and other MIPS eligible clinicians participating in the ACO (as identified on the ACO’s Participation List on March 31, June 30 and/or August 31 of the performance year). The NGAM quality performance data not submitted via the CMS Web Interface (the CAHPS survey and claims-based measures) will not be included in the MIPS quality performance category score. |
| Cost (scoring weight: 0 percent) | Not applicable. |
| Advancing Care Information (scoring weight: 30 percent) |
Each physician and other MIPS eligible clinicians participating in a NGAM ACO (as identified on the ACO’s Participation List on March 31, June 30, and/or August 31 of the performance year) reports advancing care information data to MIPS through the ordinary individual or group reporting process under MIPS. Regardless of whether this data is reported individually or as a group, CMS will subsequently calculate whether the individual reporting process or the group reporting process would have resulted in the most favorable score for a physician (or other MIPS eligible clinicians, as the case may be) and, accordingly, will attribute that most favorable score to the physician (or other MIPS eligible clinician). A single MIPS advancing care information performance category score, based on an average of the most favorable scores for all of the physicians and other MIPS eligible clinicians, will be applied to each physician and other MIPS eligible clinicians participating in the ACO. |
| Improvement Activities (scoring weight: 20 percent) |
Each physician and other MIPS eligible clinicians participating in a NGAM ACO (as identified on the ACO’s Participation List on March 31, June 30 and/or August 31 of the performance year) will automatically receive the maximum score of 40 points in the MIPS improvement activities category and will not need to report additional improvement activity information for MIPS. |
| 2017 MIPS Performance Categories and Scoring Weights | CPC+ Model |
|---|---|
| Quality (scoring weight: 0 percent) | Not applicable. |
| Cost (scoring weight: 0 percent) | Not applicable. |
| Advancing Care Information (scoring weight: 75 percent) |
Each physician and other MIPS eligible clinicians participating in a practice group that is taking part in the CPC+ Model (as identified on the group’s Participation List on March 31, June 30 and/or August 31 of the performance year) reports advancing care information data to MIPS through the ordinary individual or group reporting process under MIPS. Regardless of whether this data is reported individually or as a group, CMS will subsequently calculate whether the individual reporting process or the group reporting process would have resulted in the most favorable score for a physician (or other MIPS eligible clinicians, as the case may be) and, accordingly, will attribute that most favorable score to the physician (or other MIPS eligible clinician). A single MIPS advancing care information performance category score, based on an average of the most favorable scores for all of the physicians and other MIPS eligible clinicians, will be applied to each physician and other MIPS eligible clinicians participating in the practice group. |
| Improvement Activities (scoring weight: 25 percent) |
Each physician and other MIPS eligible clinicians participating in a practice group that is taking part in the CPC+ Model (as identified on the group’s Participation List on March 31, June 30 and/or August 31 of the performance year) will automatically receive the maximum score of 40 points in the MIPS improvement activities category and will not need to report additional improvement activity information for MIPS. |
| 2017 MIPS Performance Categories and Scoring Weights | Oncology Care Model (One-Sided and Two-Sided Risk Models) |
|---|---|
| Quality (scoring weight: 0 percent) | Not applicable. |
| Cost (scoring weight: 0 percent) | Not applicable. |
| Advancing Care Information (scoring weight: 75 percent) |
Each physician and other MIPS eligible clinicians participating in a practice group that is taking part in the Oncology Care Model (as identified on the group’s Participation List on March 31, June 30 and/or August 31 of the performance year) reports advancing care information data to MIPS through the ordinary individual or group reporting process under MIPS. Regardless of whether this data is reported individually or as a group, CMS will subsequently calculate whether the individual reporting process or the group reporting process would have resulted in the most favorable score for a physician (or other MIPS eligible clinicians, as the case may be) and, accordingly, will attribute that most favorable score to the physician (or other MIPS eligible clinician). A single MIPS advancing care information performance category score, based on an average of the most favorable scores for all of the physicians and other MIPS eligible clinicians, will be applied to each physician and other MIPS eligible clinicians participating in the practice group. |
| Improvement Activities (scoring weight: 25 percent) |
Each physician and other MIPS eligible clinicians participating in a practice group that is taking part in the Oncology Care Model (as identified on the group’s Participation List on March 31, June 30 and/or August 31 of the performance year) will automatically receive the maximum score of 40 points in the MIPS improvement activities category and will not need to report additional improvement activity information for MIPS. |
| 2017 MIPS Performance Categories and Scoring Weights | Comprehensive ESRD Care Model (LDOs and Non-LDOs with One-Sided or Two-Sided Risk Arrangements) |
|---|---|
| Quality (scoring weight: 0 percent) | Not applicable. |
| Cost (scoring weight: 0 percent) | Not applicable. |
| Advancing Care Information (scoring weight: 75 percent) |
Each physician and other MIPS eligible clinicians participating in an ESCO that is taking part in the Comprehensive ESRD Care Model (as identified on the ESCO’s Participation List on March 31, June 30 and/or August 31 of the performance year) reports advancing care information data to MIPS through the ordinary individual or group reporting process under MIPS. Regardless of whether this data is reported individually or as a group, CMS will subsequently calculate whether the individual reporting process or the group reporting process would have resulted in the most favorable score for a physician (or other MIPS eligible clinicians, as the case may be) and, accordingly, will attribute that most favorable score to the physician (or other MIPS eligible clinician). A single MIPS advancing care information performance category score, based on an average of the most favorable scores for all of the physicians and other MIPS eligible clinicians, will be applied to each physician and other MIPS eligible clinicians participating in the ESCO. |
| Improvement Activities (scoring weight: 25 percent) |
Each physician and other MIPS eligible clinicians participating in an ESCO that is taking part in the Comprehensive ESRD Care Model (as identified on the group’s Participation List on March 31, June 30 and/or August 31 of the performance year) will automatically receive the maximum score of 40 points in the MIPS improvement activities category and will not need to report additional improvement activity information for MIPS. |
Practical Takeaways
Practice groups that are currently participating in a MIPS APM or considering whether to participate in a MIPS APM should:
- Consider all of the advantages and disadvantages of participating in the MIPS APM, including whether participation in the MIPS APM, and the resulting application of the APM scoring standard, is likely to result in a higher or lower MIPS final score for the group’s physicians;
- Understand CMS’s snapshot process for determining which physician will be subject to the APM scoring standard; and
- Be aware of the March 31, June 30 and August 31 snapshot dates and, with regard to any particular MIPS APM, understand what steps the practice group can take, if any, to schedule, in concert with the snapshot dates, the addition of its physicians to, or the removal of its physicians from, the MIPS APM.
If you have questions or would like additional information about this topic, please contact Tim Kennedy at (317) 977-1436 or tkennedy@wp.hallrender.com or your regular Hall Render attorney.
[1] Although this article references physicians, the definition of “MIPS eligible clinician” also includes physician assistants, nurse practitioners, clinical nurse specialists and registered nurse anesthetists. These other health care professionals are equally subject to the APM scoring standard described in this article.
[2] Simply stated, CMS will deem a physician to be participating in a MIPS APM if, on March 31, June 30 or August 31 of a MIPS performance year, the physician was on the “Participation List” of an “APM Entity” taking part in a MIPS APM. An ACO is the APM Entity for both the Medicare Shared Savings Program and the Next Generation ACO Model. A practice group is the APM Entity for the CPC+ Model and the Oncology Care Model. In the Comprehensive ESRD Care Model, the APM Entity is an ESRD Seamless Care Organization (“ESCO”).
