What is the Cost performance category included in MIPS?
Measuring cost is an important part of MIPS because cost measures show:
- The resources clinicians use to care for patients.
- The Medicare payments (for example, payments under the Physician Fee Schedule, IPPS, etc.) for care (items and services) given to a beneficiary during an episode of care. An episode of care is the basis for finding items and services from claims given in a specified timeframe.
What are Cost Measures?
For 2018, MIPS uses cost measures that cover the total cost of care during the year or during a hospital stay. The Cost performance category uses your Medicare claims data to collect Medicare payment information for the care you gave to beneficiaries during a specific period of time. Because CMS uses Medicare claims data, they will calculate the Cost performance category score and you don’t have to submit any data.
For the 2017 transition year, the Cost performance category didn’t count toward your total MIPS score. In year 2, it counts for 10% of your total MIPS score. CMS believes that the 10% cost weight in 2018 will help you:
- Have an easier transition to the 30% cost weight MACRA requires starting with the 2019 MIPS performance period.
- Review and understand your performance cost measures.
If you participate in a MIPS Alternative Payment Model (APM), the MIPS APM will apply a 0% weight to the Cost performance category because many MIPS APMs measure cost in other ways.
What are the Year 2 Cost Measures?
In year 2, CMS will only use two cost measures to measure performance:
- Total Per Capita Cost measure
- Medicare Spending Per Beneficiary measure
Details about the Total Per Capita Cost (TPCC) Measure for MIPS
The TPCC measure measures all of Medicare Part A and Part B costs during the MIPS performance period. For the TPCC measure, beneficiaries are assigned to a single Medicare Taxpayer Identification Number/National Provider Identifier (TIN-NPI) in a two-step process that considers:
Only beneficiaries who received a primary care service during the performance period are assigned to the TIN-NPI. Primary care services include:
Here are the two steps used to assign beneficiaries to a TIN-NPI for the TPCC measure:
See the CMS Cost performance category fact sheet for additional details on the TPCC measure.
Details about the Medicare Spending Per Beneficiary (MSPB) Measure for MIPS
The MSPB clinician measure determines what Medicare pays for services performed by an individual clinician during an MSPB episode: the period immediately before, during, and after a patient’s hospital stay.
An MSPB episode includes all Medicare Part A and Part B claims during the episode, specifically claims with a start date between three days before a hospital admission (the “index admission” for the episode) through 30 days after hospital discharge.
The MSPB measure is assigned to individual clinicians, as identified by their unique TIN-NPI. MSPB measure performance may be reported at either the clinician (TIN-NPI) or the clinician group (TIN) level.
How are Cost Measures calculated in 2018?
Cost measures are risk adjusted to account for differences in beneficiary-level risk factors that can affect quality outcomes or medical costs, regardless of the care provided. The goal of risk adjustment is to enable more accurate comparisons across Medicare Taxpayer Identification Number (TINs) that treat beneficiaries of varying clinical complexity, by removing differences in health and other risk factors that impact measures outcomes but are not under the TIN’s control.
How will I get Performance Feedback?
You may have already been getting feedback for several years on cost measures from the Value Modifier program reports and the Physician Feedback Program, Quality and Resource Use Reports (QRURs). In 2018, CMS will give you feedback on cost measures used in the 2017 MIPS transition year. Although the Cost performance category doesn’t affect your payments for the transition year, CMS will still give you performance feedback to help you get familiar with cost measures.
How will I be Scored?
CMS will calculate your Cost performance if the case minimum of attributed beneficiaries (i.e., 20 cases for total per capita cost measure, or 35 cases for MSPB measure) is met. If the case minimums aren’t met for either of the 2 measures, CMS will reweight the Cost performance category weight to the Quality performance category. This will make the Quality performance category worth 60% of your 2018 MIPS total score.
To determine your Cost performance category score, CMS will:
- Assign 1 to 10 points to each measure
- Compare your performance to other MIPS eligible clinicians’ and groups’ during the performance period, not on a past year.
The Cost performance category score is the average of the 2 measures, but if only 1 measure can be scored, that score will be the performance category score. The table below illustrates scoring for an example group participating in MIPS.
This group’s Cost performance category is (14.6/20) which is equal to a cost performance category percentage score of 73%. Because the cost performance category is worth 10 points in the MIPS final score, this group would earn 7.3 points towards their MIPS final score.