Merit-Based Incentive Program

By Donna Kurek, MSN, RN, MHA, ONC, CMSRN, CPHQ, FNAON
President- National Association of Orthopaedic Nurses (NAON)

The Merit-Based Incentive Program System (MIPS), implemented in 2017, is a federal program established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MIPS aims to help transform healthcare from a fee-for-service to a pay-for-value system.   MIPS is part of the quality Payment Program. Members of an ACO or Advanced Payment Model program are not required to report MIPS (MDinteractive, 2024). Practices that terminated an ACO or advanced payment program are now faced with adding an MIPS model to achieve compliance. MIPS measures affect a percentage of physician payments based on compliance with specific categories. There are four categories (AMA, 2023):

• Quality (30% of score): Measures related to quality performance.
• Cost (30% of score): Evaluate the costs of care, including the use of resources.
• Promoting Interoperability (25% of score): Focuses on measures with EHR utilization.
• Improvement Activities (15% of score): Practice improvement initiatives

     Points are based on national benchmarks. Therefore, providers are scored against every other practitioner in the country.   MIPS is also budget neutral, meaning high-performing providers will earn significant savings, whereas low-performing providers may be forced to pay a penalty. The adjustment for 2022 was set at +/- 9% and is applied to the 2024 Medicare Part B payments for professional services fees. If a provider is not participating in MIPS, he/she will face a negative payment adjustment of the entire 9% in 2024 (MDinteractive, 2024). Low performers will fund the higher performers, which can last beyond the initial payment year.

     Since MIPS focuses on improving the quality of care, there is high value in the need to select reportable quality measures that positively impact the practice's performance. Selecting these measures may be challenging in the traditional MIPS pathways as many available measures do not apply to orthopaedics. Many orthopedic-specific measures cannot be sent via the EHR, requiring a cost for a third-party vendor to manage the data (qpp.gov). Medicare is now offering a new pathway: MIPS value pathways or MVP. The MVP pathway is voluntary and will eventually become required in 2028 (MDinteractive, 2024). The MVP currently offers "Improving the care of the lower extremity joint repair value pathway. The measures applied to the orthopaedic patient make it more efficient to manage in the orthopaedic practice setting. The new MVP pathway allows organizations to report on a smaller set of activities and quality measures more relevant to the practice specialty. Transitioning to the MVP measures before the 2028 requirement may prove beneficial to avoid penalties.

References

Merit-based incentive payment system (MIPS) - what is MIPS? (2016, September 25). MDinteractive. Retrieved April 29, 2024, from https://mdinteractive.com/MIPS

Mips value pathways (MVPs) - qpp. (n.d.). https://qpp.cms.gov/mips/mips-value-pathways

Understanding Medicare's merit-based incentive payment system (MIPS). (n.d.). American Medical Association. https://www.ama-assn.org/practice-management/payment-delivery-models/understanding-medicare-s-merit-based-incentive-payment