MHA FPX 5068 Assessment 1 Merit-Based Incentives and Daily Operations MHA-FPX 5068 Leadership, Management and Meaningful Use of Health Care Technology Merit-Based Incentives and How They Affect Daily Operations

The Merit-Based Incentive Program System (MIPS) was established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This act came into effect in January 2017 and impacts the healthcare industry by transforming from a fee-for-service to a pay-for-value model. MIPS is designed to determine Medicare payment adjustments. Using a composite performance score, eligible clinicians may receive a payment bonus, a payment penalty, or no payment adjustment (Centers for Medicare and Medicaid Services [CMS], 2021). The organization reports the measures and activities they collect during the performance period. CMS collects and calculates cost measures for the organization. The four performance categories—quality, improvement activities, promoting interoperability, and cost—are scored and make up the final MIPS score. The payment adjustment applied to the Medicare claim is determined by the final score. Medicare’s legacy quality reporting programs were consolidated and streamlined into MIPS. This consolidation reduced the aggregate level of financial penalties physicians otherwise faced and also provides a greater potential for bonus payments (Rathi, 2019).

There may be benefits of MIPS, but there are also significant challenges. MIPS is a new reimbursement program for Medicare and Medicaid services that has both drawbacks and gains for provider payment. Lack of incentive is one drawback for providers participating in MIPS. Providers participating in an alternative payment model will be qualified to receive financial incentives. Providers in MIPS or fee-for-service reimbursement models will not be qualified to receive any bonuses and will have a lower reimbursement rate than those participating in alternative payments.

MHA FPX 5068 Assessment 1 Merit-Based Incentives and Daily Operations

Shortcomings in aligning stakeholders is a further challenge that MIPS faces. Simplifying quality measures under alternative reimbursement programs and MIPS, like the Physician Quality Reporting System, will help decrease this challenge. To benefit beneficiaries, it is important for quality data to be in a user-friendly form (Berdahl et al., 2019). Challenges with documentation standards create difficulties in aligning beneficiaries among payers and providers. The lack of alignment between Medicare, Medicaid programs, and commercial payers regarding quality measures has led to a significant burden on providers concerning performance improvement (Johnson et al., 2020). It is vital for organizations to collaborate with payers, providers, healthcare associates, and quality measurement professionals to reduce challenges with the payment system.

According to Eggleton et al. (2020), there are three exclusions of providers from MIPS eligibility. First, providers participating in an APM, as defined by MACRA, are not qualified to participate in MIPS. Second, clinicians who report less than $90,000 in Medicare beneficiaries in a specified period or provide services to less than 200 Medicare patients a year are exempt from MIPS. CMS conducts low volume status determinations prior to and during the performance period using claims data. Finally, providers who enroll in Medicare for the first time during a performance year are exempt from MIPS until the next subsequent performance year.

Meeting Measures of Merit-Based Incentives

With the implementation of MIPS, providers were challenged with limited knowledge of ways to adequately meet measures to prevent penalties. It is imperative for clinicians to select appropriate measures. Clinicians must evaluate and identify their organization’s strengths and weaknesses with quality reporting (Rutherford et al., 2017). After identifying strengths, clinicians should utilize MIPS measures that will maximize performance. Eligible clinicians can receive maximum points by reporting on only six of 271 quality measures and four of 93 improvement measures. Practices should invest in MIPS technology to assist with incentives and avoid penalties. Collaborating with current EHR vendors enhances clinician productivity, increases MIPS performance scores, and supports the additional benefit of EHR support. It is vital for the EHR system to have the ability to incorporate reporting requirements into clinician workflows.

With the assistance of the EHR system, organizations can anticipate positive MIPS payments and avoid penalties. Currently, providers’ positions on MIPS have hampered implementation. Utilizing physicians to educate their peers on MIPS and its financial implications may assist with MACRA implementation challenges (Horvitz-Lennon et al., 2022). It is important to motivate staff across the organization to work as a team to achieve MIPS goals (Horvitz-Lennon et al., 2022). Utilizing a physician as a MIPS champion can help overcome the reluctance towards MIPS. This will also in