By Caroline Fife and Lindsay Horst
We’ve been asking you to download your Field Test report for the “non-pressure ulcer” Cost Measure. This issue is important because in the future, CMS can claw back Medicare dollars from a wound care practitioner based on their performance on the future cost measure. I have been trying to understand how much of a financial risk the proposed cost measure could create for a wound care practitioner and the answer is not easy to figure out or explain. I asked Lindsay Horst from Linden Healthcare Consulting to help me figure this out. As a MIPS consultant, she’s seen the way that cost measures in other specialties have impacted practitioners. I am very grateful for her help on this!
How your MIPS score is calculated
First, let’s talk about how the MIPS score is calculated. If you are confused about how MIPS calculations work, this first section will help you understand the big picture of MIPS. There are theoretically 4 components of the MIPS score: Quality, Improvement Activities (IAs), Promoting Interoperability (PI) and Cost. Right now, most wound care practitioners are only scored on a maximum of 3 categories since there is no relevant cost measure. However, not every practitioner is even scored on these 3 remaining categories. For example, all hospital-based practitioners and all practitioners in small practices (defined as 15 or fewer NPIs billing under the TIN) are exempt from the Promoting Interoperability (PI) category. If a practitioner is exempt from PI and also has no relevant cost measure, their entire MIPS score is based on only two components: Quality and Improvement Activities (IAs)! In that scenario, Quality is worth 50% of the final MIPS score and IA is worth 50%. This is the situation for perhaps the majority of wound care practitioners in the absence of a cost measure. For practitioners in large, hospital-based groups who are not scored on cost, Quality jumps to 85% of the final score, with IAs only worth 15%. (I hope the HOPD doctors read that last sentence carefully.)
How your MIPS score impacts your Medicare payment
This article pertains to “MIPS eligible” wound care practitioners. If you are required to participate in MIPS, CMS euphemistically calls that being “eligible.” If you are eligible and do nothing about reporting, you will experience some sort of monetary penalty (“negative payment adjustment”) to your Medicare claims. IF you are required to participate in MIPS and if you ignore MIPS entirely– one of two things will happen: 1) if no cost measure is relevant to you, you will experience the full 9% penalty, or 2) if there is a relevant cost measure, the worst penalty you can experience is 5.4% of your Medicare claims. This is the first interesting point about having a relevant cost measure. It might help you avoid the maximum penalty if you have been ignoring the reporting requirements entirely.
Within MIPS, practitioners achieve a total score from 0 to 100 based on the points obtained from each applicable category. Each year, CMS sets a numeric performance threshold required to avoid a penalty. Right now, the minimum MIPS score a practitioner has to achieve to avoid a penalty is 75 out of a possible score of 100. If you score above 75, you will get a positive adjustment (“bonus”), and if you score below that, you will get a negative adjustment (“cut”). Remember that payment adjustments are applied to your actual Medicare payments (not the Medicare allowable) for Part B professional services only (not all Part B payments).
The penalties that result from any given MIPS score can easily be calculated in advance based on how far the score was below the threshold. For example, if the threshold is 75, a score of 70 would earn a Medicare cut of -0.6%, and a score of 60 would earn a -1.80% cut. However, the upward payment adjustments cannot be calculated in advance because MIPS is a “zero sum game.” The amount of bonus money available for high performers (practitioners who score above the threshold) is determined by the pool of money clawed back from all the practitioners getting a Medicare cut. That means that the exact amount of a Medicare bonus varies from year to year, so we can’t know for sure how much it will be in advance. However, we can use past experience as a guide. In 2023, a clinician with a perfect MIPS score of 100 earned a mere +2.15% bonus, and in 2024, a perfect score earned a practitioner a pitiful +1.05% bonus. Thus, we can estimate that for the 2025 performance year, a final MIPS score of 85 would likely earn a practitioner a bonus between 0.4% and 0.9%. Bonuses and penalties are applied two years after the performance year, so a bonus earned for 2025 MIPS will be applied to the practitioner’s 2027 payments. That’s the background you need to understand how the scores on the cost measure could hurt (or help) you – so keep reading.
When does a Cost measure apply to a practitioner?
In the case of the non-pressure ulcer cost measure, a practitioner would be “scored” on the cost measure if they have 20 eligible “episodes.” For now, let’s skip the complicated conversation around how CMS decides if a cost measure applies to a practitioner, and assume that CMS has decided to score you on the new non-pressure ulcer cost measure.
How a Cost measure contributes to the MIPS score
If a practitioner has a cost measure that is applicable to their practice, the cost category is almost always weighted at 30% of the total score.
When the new wound care cost measure is available as part of MIPS, here’s how scoring will work based on your practice size and site of care:
- For small practices (HOPD and office-based/mobile):
- Quality: 40%; Improvement Activities: 30%; Cost: 30%
- For large, office-based/mobile practices:
- Quality: 30%; Improvement Activities: 15%; PI: 25%; Cost: 30%
- For large hospital-based practices:
- Quality: 55%; Improvement Activities: 15%; Cost: 30%
How the Cost measure itself is scored
All Cost Measures have a minimum score of 1 and a maximum of 10. Remember that in general, the higher your Medicare spending (charges), the lower (worse) your cost score should be, and the lower your Medicare charges are in comparison to your “peers,” the higher (better) your cost score should be. Unfortunately, the appropriate use of many services could cause a practitioner to appear to be “overusing” Medicare resources. As only one example, if you often send patients to the cath lab for revascularization or obtain MRIs to evaluate for osteomyelitis (both of which are components of high-quality care), your Medicare charges could look excessive compared to less conscientious practitioners. The devil is in the details of how the cost measure is calculated, and the peers to whom your costs are compared. That’s why it is imperative for everyone to review their Field Test report carefully.
Perhaps the biggest problem with any of the cost measures that CMS has created so far is that CMS does not provide meaningful or actionable feedback in the cost report. In the previous non-pressure ulcer Field Test, it was impossible to understand how a wound care practitioner could make changes in their practice based on the data, other than to reduce services to Medicare beneficiaries. This remains a huge problem for all cost measures.
How a Cost measure can impact your MIPS score
Once a single cost measure applies to a provider, the cost category is included in their final score. This causes the value of the other MIPS categories to decrease to make room for the cost category. Whether this helps or hurts you depends on your special statuses and your other category scores, in addition to your cost score.
Consider the scenario of a large, hospital-based practice: they do not have to report PI, so without a cost measure, quality is worth 85% of their final MIPS score. Unfortunately, Quality performance is a problem for wound care practitioners because only two widely available quality measures are remotely relevant to wound care, and most of the other measures that could be reported are worth less than the full 10 points. In this scoring scenario, adding the cost category takes quality from 85% to 55% of the final score. If their quality scores are low, making that category worth less could help them avoid a cut.
However, for a small practice with no cost measure, adding the cost category usually decreases the final score. Without a cost measure, Improvement Activities are worth 50% of the final score. Since IA is the easiest category of MIPS (every provider should be getting a 100% score every year in IA!), reducing the value of their highest-scoring category will usually reduce their overall MIPS score.
Here’s the bottom line: Whether the cost score helps or hurts a practitioner depends on their performance in the other areas of MIPS, and their special statuses.
Final thoughts
Wound care is not a specialty, and without a specialty code, non-podiatrists have no mechanism by which to identify themselves to CMS as wound care practitioners. My boards are in Family Practice, and I do not want CMS to evaluate my Medicare spending in relation to other FPs because my patients are much sicker than those seen by the typical FP (and thus my patients’ Medicare costs are higher). Years ago, I posted a blog about my 2016 Quality and Resource Report (QRUR) when CMS assumed that I was the primary care provider for all my wound care patients . CMS unfairly applied the primary care cost measures to me and I got the lowest possible score for total Medicare spending. A wound care relevant cost measure is a better way to compare my Medicare spending than comparing me to other FPs.
CMS is going to create a wound-relevant cost measure no matter what. Let’s make sure it is as accurate and fair as possible. We want CMS to have a better understanding of wound care patient costs and the factors that contribute to cost (e.g., multiple wounds, CHF, etc.). We want the Cost Measure to correctly assign the costs that are under our control. Using the results from your Field Test reports, we can provide feedback to CMS/Acumen and thus impact the way that wound care costs are evaluated. Through the advocacy of the Alliance of Wound Care Stakeholders and the APMA, we can insist that we are provided with the data we need to understand the scoring and that CMS provide us with actionable recommendations based on the cost score.
The post How a Non-Pressure Ulcer Cost Measure Could Help or Hurt Your MIPS Score (and Your Medicare Payments) appeared first on Caroline Fife M.D..