Proposed efforts to keep smaller providers out of the Merit-based Incentive Payment System poses a blow to large health systems that have spent millions to implement the CMS' pay program.
For the second year in a row, the CMS proposed that physician practices with less than $90,000 in Medicare revenue or fewer than 200 unique Medicare patients per year would be exempt from MIPS.
Under MIPS, doctors must hit certain quality thresholds. Those who don't must pay a penalty that is redistributed to the high performers.
So as more doctors get a pass, the size of the incentive pool has shriveled substantially. With all the opt-outs, approximately 40% of the 1.5 million doctors billing Medicare will have to comply with the system.
"We are concerned that the incentives to participate in MIPS are reduced if positive payment adjustments are insufficient to help offset the investments that practices and health systems must make to succeed under MIPS," Tina Weatherwax Grant, vice president public policy and state advocacy at Trinity Health, said in a Sept. 10 comment letter.
Practices were initially eligible for $833 million in incentive payments under MIPS in 2019, but it could fall to $118 million in 2020.
The CMS should reverse course on the opt out to ensure adequate rewards for those that remain in MIPS and to make sure quality of care will improve for seniors, according to Dr. Jerry Penso, CEO of the AMGA.
"With such small payment adjustments, it becomes an open question if eligible clinicians will fully engage in the program over time or if MIPS will become a check-the-box compliance exercise for those required to participate. If you exclude a significant percent of providers," Penso said in a comment letter, it could have a negative effect on Medicare's tens of millions of fee-for-service beneficiaries.
The CMS' decision to allow so many to opt out is disappointing to major health systems like Trinity, since it has made substantial investments in staffing, electronic health records and internal patient portals to get MIPS off the ground, Grant said.
The CMS may address this concern by expanding eligible MIPS clinicians to include physical therapists, occupational therapists, clinical social workers and clinical psychologists.
For 2021, practices are eligible for up to $372 million in incentive payments as a result of the proposed additions.
It's unclear however if these providers are ready to join the program or have made the technological upgrades needed, Grant said.
There is debate over how the CMS will track these new providers' performance under MIPS, according to Clara Evans, director of public policy and fiscal advocacy at Dignity Health.
The new clinician types may be billing under a hospital's tax identification number, or TIN. However, some providers in MIPS are tracked under their national provider identifier, or NPI.
"CMS should clarify whether it intends to exclude these hospital-employed clinicians from the MIPS, or whether it would update billing instructions so that hospitals must report the NPIs of these clinicians," Evans said in a comment letter. "This step likely would be necessary since CMS relies on TIN/NPI combinations to identify MIPS-eligible clinicians."