Although somewhat familiar with CMS’s MIPS and MSSP programs, many healthcare providers have questions about the differences between the two. MIPS (Merit-Based Incentive Payment System) is currently CMS’s largest value-based care payment program and is designed to move the healthcare industry toward transformation from fee-for-service to pay-for-value care. MIPS is mandatory for all providers who receive $90,000 in Medicare part B payments AND provide care for more than 200 Part B-enrolled Medicare beneficiaries AND bill more than 200 professional services per year. 

CMS and Congress (through the Bipartisan Budget Act) manage MIPS through the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA requires CMS to publish each eligible clinician’s annual MIPS score and performance category scores within approximately 12 months after the end of the relevant performance year. Consequently, more than half-a-million 2017 MIPS scores became publicly available in early 2019, all identifiable by clinician and group. Third-party consumer websites are able to access the data files containing scores and clinician ratings against national peers on a scale of 0 to 100. In addition, a 5-star rating scale is applied to every MIPS quality measure for purpose of peer comparisons. MACRA also mandates that CMS must gradually increase the MIPS performance threshold each year towards becoming the national historical mean or median in the 2022 performance year. For this reason, MIPS can be likened to a “treadmill” which increases in speed and trajectory over time, motivating organizations and clinicians to put quality incentive programs in place now in order to stay ahead of the competition as the program gets more difficult.

MIPS eligibility includes the eligible clinicians in the categories below who bill for Medicare Part B (otherwise known as the Physician Fee Schedule) or Critical Access Hospital (CAH) Method II payments assigned to the CAH.

Providers included in MIPS eligibility include:

• 2017 and 2018 performance years: MIP requirements initially included physicians (MD/DO and DMD/DDS), physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists
• Additions for 2019 performance year: MIPS expanded to include physical and occupational therapists, speech-language pathologists, audiologists, clinical psychologists, and registered dietitians or nutrition professionals

MSSP (Medicare Shared Savings Program) is an alternative payment model in which eligible providers and hospitals are rewarded for achieving better health for patients, improving population health, and reducing costs for healthcare. To participate in MSSP providers must be part of an Accountable Care Organization (ACO), a patient-centered network which shares medical and financial and responsibilities. MSSP’s goal is the improvement of patient care while curbing unnecessary spending with the promotion of accountability for a patient population and coordination of services under Medicare Parts A and B. The initiatives encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery. MSSP evaluates eligible clinicians on measures related to resource utilization, calculated using Medicare claims, patient experience surveys, and chart-abstracted quality measures.

As part of healthcare’s move from the fee-for-service focus to value-based care, St. Elizabeth participates in CMS’s MSSP program through the St. Elizabeth Provider Network (SEPN) and the ACO Healthcare Solutions Network (HSN). In 2018 MSSP transitioned from Pay-for-Reporting to Pay-for-Performance. In this third year of MSSP the shift focuses upon performance in the measures below and will have a large financial impact on providers and the institution. St. Elizabeth’s participation in MSSP benefits our providers by also satisfying the required MIPS participation and saving the providers from having to complete this tedious process on their own.

MIPS performance is scored based on three domains: Quality, Promoting Interoperability, and Improvement Activities. MSSP performance is based on four domains: At-Risk Population, Patient/ Caregiver Experience, Preventative Health, and Care Coordination/ Patient Safety. 

St. Elizabeth participates in MIPS and MSSP through the ACO (Accountable Care Organization) Healthcare Solutions Network, a partnership between SEPN and TriHealth. 2017 performance resulted in a positive payment adjustment of 1.64% (the highest possible for performance year 2017) for the SEPN physician providers payable throughout this year, 2019. 2018 performance will result in a 1.68% positive payment adjustment (the highest possible for performance year 2018) made payable to providers in 2020. See below for HSN and SEPN’s performance in the chart-abstracted quality measures as well as the overall MIPS and MSSP performance.

For any questions, please feel free to contact Shelley Simpson at 301-7335.