The Challenge of Positive MIPS Reimbursement Adjustment | OBERD


Achieving a positive reimbursement adjustment just got a bit harder.

The merit-based incentive payment system (MIPS), established by CMS, encourages the transition to value-based delivery of health care by outlining a system of adjustments to Medicare reimbursement based on performance. The MIPS scoring system calculates a Composite Performance Score (CPS) for each provider—a total of 100 points is possible from a weighted sum of scores on four performance categories: Quality, Advancing Care Information (ACI), Clinical Practice Improvement Activities (CPIA), and Cost.

For performance year 2018, clinicians with a CPS lower than 15 (or those who do not participate in MIPS) will receive a negative adjustment, not to exceed 5%. A CPS of at least 15 ensures a neutral or positive adjustment, and providers with a score of 70 or higher will receive an additional adjustment in recognition of exceptional performance. The MIPS scoring guide asserts: “The amount of the positive adjustments is scaled and will depend on the scores as well as the total number of clinicians both above and below the performance threshold.” The maximum reward and penalty percentages will both increase in the coming years:


Note that achieving a positive reimbursement adjustment will be more challenging for MIPS performance year two. As discussed in our MIPS 2018 update, CMS has modified several of the fundamental elements that underlie the computation of CPS, effectively making it harder to achieve a positive adjustment. From performance year one to year two, the required data completion rate increases from 50% to 60%. In addition, the ranges that define the deciles used by CMS to benchmark quality measures of performance have shifted upward:


The weight given to quality performance scores for CPS calculation also changes in MIPS performance year 2018, dropping from 60% in 2017 to 50%. This weighting drops again to 30% in 2019. This reduces the impact of quality scores when determining CPS for reimbursement. These factors are important to consider when determining a pragmatic MIPS strategy for the future.

What does MIPS success look like? Knowing that MIPS incentives are calculated to evolve over time, it’s worthwhile for providers to reflect on what success under MIPS means for their practice. Using MIPS as a catalyst for strategic business planning, context-specific goals can be defined. Here, we outline three equally plausible “success paths”.

For some providers, securing positive reimbursement adjustments will be paramount. Careful planning and implementation of measures with benchmarking capabilities can set the stage for performance scores that confer the highest adjustments. When collected and reported through a Qualified Clinical Data Registry (QCDR), both Quality and CPIA scores can be high, and together will contribute 65% to the CPS calculation in 2018.

For other clinicians, simply avoiding a negative adjustment constitutes success. Electronic collection of outcomes data satisfies MIPS’ CPIA performance measurement, which contributes 15% to the total CPS. A QCDR can achieve this and this score in and of itself will guarantee avoidance of a negative reimbursement adjustment for the 2018 performance year.

A third path for 2018 forgoes the pursuit of a positive adjustment, avoids the penalty, and refocuses a provider toward collecting the most meaningful data for their specialty. Using a specialty-specific QCDR ensures that the data collected is context appropriate, and intelligently informs the delivery of higher quality health care for their practice. Better care paths for individual patients may be revealed by benchmarking their condition and outcomes against aggregated volumes of comparable data. An efficient approach under this scenario is the collection of outcomes data through a QCDR such as OBERD that has Specialized Registries using forms recommended by the American Association of Orthopaedic Surgeons (AAOS).

In subsequent posts, we will explore these recommended success paths in greater detail.

OBERD MIPS Strategic Recommendation: Pursue a Reimbursement


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