According to CMS, to earn a positive payment adjustment — or bonus — under MIPS, physicians who participate in Medicare Part B can earn the bonus in 2019.

To earn the bonus, physicians must show high-quality, efficient care by documenting their information for the following four metrics:

  • quality, which replaces the Physician Quality Reporting System (PQRS);
  • improvement activities, which is a new category;
  • advancing care information, which replaces the Medicare electronic health record incentive program (Meaningful Use);
  • cost, which replaces the value-based modifier.

Data from 2017 will be used for each of the categories, except for cost, which instead will use 2018 data.

To earn the first positive MIPS payment adjustment, physicians must submit 2017 data by March 31, 2018. Those who participate in an advanced APM in 2017 will earn a 5% incentive payment in 2019.

“MIPS produces a numerical score, and depending on that score, you qualify for no change in payment, a bonus, or a penalty,” says Keith S. Naunheim, MD, professor of surgery at Saint Louis University School of Medicine in St. Louis.

“One-third, or about 30%, of that score has to do with something that you as a practitioner have a hard time really controlling, and that is the resource utilization,” he says. “That will be determined by CMS.”

CMS calculates the resource utilization. “They look at patients attributed to you and say, ‘Around the time of this person’s surgery, you used these resources,’” Naunheim explains.

Sometimes, the list of resources CMS displays is a valid list, but sometimes it’s not, he notes.

“If I, as a surgeon, am operating on someone who is on the cusp of renal failure or who is undergoing dialysis, and I do the operation and then the patient has dialysis for two to three months and later has a transplant, then CMS will look at this and say, ‘Dr. Naunheim’s patient had dialysis and a transplant,’ when all I did was a bronchoscopy.”

In this example, the surgeon is tagged with hundreds of thousands of dollars’ worth of resource utilization, but the physician did not have anything to do with the money spent.

“How do you attribute those costs and allocate them to different practitioners, all of whom saw the patient in a 30- to 60-day period,” Naunheim asks.

This kind of situation likely will lead to doctors cherry-picking their patients, he says.

Also, MIPS creates definite losers, even if all doctors are improving on the metric scores.

“They’re not putting any more money into it, so if I get a 5% bonus, somebody else gets a 5% cut,” Naunheim says. “That’s a model that we as a profession don’t like. It’s not necessarily fair to people who get penalized.”

Some providers could be penalized even if they’re providing high-quality care, he adds.