MHAFPX5068_MercadoAngelique_Assessment1-2
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Vila Health: Merit-Based Incentives and Daily Operations
Angelique Mercado
Capella University
MHA-FPX5068 Leadership, Management and Meaningful Use of Health Care Technology
Dr. Madeline Meyer
October, 2023
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Merit-Based Incentive
The future of healthcare has evolved and continues to evolve as innovation and
technology are dominant forces driving changes for the better. While many hospitals and
providers have adopted an EHR system (Electronic Health Record), the continuous focus is
ensuring patients are receiving high quality care and reimbursing those physicians that do so.
With the inception of Merit-Based Incentive Payment System (MIPS) in 2015 to measure
providers performance in 4 areas; quality, costs, practice improvement and promoting
interoperability will rewards providers for value vs volume of patients treated (Khullar et al.,
2021).
Organizations such as Vila Health have concerns about the effects of meeting MIPS is
having on the overall operations.
How MIPS affects Daily Operations
There have been mixed feelings according to Vila Health leadership as providers have
adapted to new workflows as a result of the implementation of MIPS. MIPS evaluates clinicians
based on these 4 areas of performance and as a result has prompted review of the benefits and
challenges. Most of the interviews conducted within Vila Health uncovered that while many
understand the importance of MIPS, the consensus is, it does negatively affect daily operations.
While it has become easier to find the information, inputting the data takes longer, providers are
seeing less patients, and want to ensure MIPS is implemented into the EHR as an effort to
minimize burden. According to a study conducted by Khullar et al. (2021), which corresponds to
the sentiments of Vila Heath leadership, there is high administrative burden due to the frequent
MIPS changes in score domains and requirements each year, some physicians are scheduling less
patients due to the burnout and some have to hired more staff to handle the time and cost
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allocated to invest in the MIPS related activities. The reward is small for the costly work put in to
avoid penalties which is adding to the loss in revenue and decrease in morale from staff.
Meeting Merit Based Incentives
The 6 steps to beginning the MIPS process is: verifying providers eligibility using QPP
(Quality Payment Program) Participation Status Tool, selecting a reporting option such as
Traditional MIPS, MIPS APM (Alternative Payment Model), and MIPS Value pathways,
choosing a participation option such as individual or group, select and perform measures activity
which allows providers to select 6 measures and collect data for each, verify final eligibility and
finally submit your data. Traditional MIPS program requires providers to select 6 out of 198
MIPS quality measures for a calendar year and collect data on each and 2 high weighed activities
during a 90-day period.
Vila health has decided on ideas to ensure providers meet the merit-
based incentives: 1. Make sure we connect MIPS templates to workflow to ensure usability and
efficiency within the EHR system 2. Possibly evaluating any bottlenecking within workflow and
MIPS criteria to revise and ensure standardization.
After meeting the initial eligibility for MIPS providers have 5 options to participate: as an
Individual, Group, Virtual group, Subgroup and APM Entity. Based on this, a provider will report
and measure activity using 1 of the 3 reporting options available in 2023 which are 1. Traditional
MIPS, the provider will select quality measures and improvement activities, while cost is
collected and calculated by CMS. 2. APM Model (Alternative Payment Model), the providers or
group will report quality measures and promoting interoperability
from a fixed measure set, Improvement activities will receive full credit as it will be evaluated
each year. Finally, 3. MIPS Value Pathways (MVP’s), this new reporting option for 2023
provides groupings of measures relative to a specialty or medical condition. With MVP’s there is
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a reduced number of quality measures and improvement activities, allowing providers to show a
more accurate assessment of the quality of care. Also, providers will complete the Promoting
Interoperability activities, while CMS will collect and calculate data for Cost performance
category. After the selection of reporting type, providers should make themselves aware of the
weight of each performance category. According to QPP (2022), the 2023 Traditional MIPS
performance activities are as follows: Quality is 30%, Cost is 30%, Improvement Activities is
15%, and Promoting Interoperability is 25%. The weight of the 4 categories will result in a final
score of 0-100 points, in turn, determining a positive, negative, or neutral MIPS payment
adjustment based on Medicare Part B value you provide. The threshold to avoid penalty for 2022
is 75 points or neutral, scoring below this will result in a penalty up to -9%, above the 75 points
will result in a positive payment adjustment with clinicians scoring 89 points or higher receiving
an additional adjustment for exceptional performance. The collection of performance data is
based on a previous calendar year and submitted the following year. Payment adjustments are
made within the following year, therefore, if a provider is collecting data based on the 2023 year,
he/she will receive performance feedback in late 2024 and payment adjustments later in 2025.
The payment adjustments for 2023 are based on the 2021 performance; payments penalized
providers up to 9% or rewarded them up to 2.33%. Scoring and payment rules are changing as
the requirements change yearly.
Failure to Meet Merit-Based Incentives Impact
Failing to meet the MIPS program will result in lower scores thereby lower
reimbursements or penalties to be paid by the provider. Clinicians scoring below the 75-point
threshold are subject to a penalty up to 9%. Many providers worry that the steps to meeting
MIPS places burdens upon the staff and provider to change how they conduct business.
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According to the AMA (2023), the administrative shortcomings of 2019 MIPS compliance may
require up to 53 hours per year of a physician’s time and cost $12,800 in administrative tasks
lost. This may mean hiring more staff or designating administrative staff to assist with gathering
data or reviewing patient histories to determine risk factors to avoid penalty; thereby
jeopardizing access to care for specific groups of patients. As stated by Berdahl et al. (2019),
providers argued seeing vulnerable patients put them at a higher risk for penalties, such as
patients who refused services or social needs. To support this claim, Khullar et al. (2021) studied
social risk and physician performance scores during the 2017 MIPS inception, which uncovered
that clinicians serving lower income patients often had lower performance scores, providers
serving more Medicare and Medicaid patients had lower MIPS scores and subspecialties such as
OB/GYN’s reported lower sores. This did prompt CMS to introduce an up to 5-point bonus for
clinicians serving Medicare/Medicaid patients called “complex patient bonus”, however, the
bonus is not enough to boost the MIPS scores (Khullar et al., 2021). MIPS’ goal is to provide the
healthcare environment with a standard of quality of care to be attainable by all providers, if they
are looking at MIPS as a roadblock to care then it will seem as though it is impeding patient care.
If the EHR system is not supportive of evaluating the MIPS information entered by providers
then, it will seem as it is working against the physician, causing more workflow issues. This will
be the organizations responsibility to ensure the EHR assists with inputting MIPS data or
improvements need to be made with data collection.
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References
American Medical Association. (2023).
Merit-based incentive payment system (MIPS)
.
https://www.ama-assn.org/system/files/medicare-basics-mips.pdf
Berdahl, C. T., Easterlin, M. C., Ryan, G. W., Needleman, J., & Nuckols, T. K. (2019). Primary
Care Physicians in the Merit-Based Incentive Payment System (MIPS): a Qualitative
Investigation of Participants’ Experiences, Self-Reported Practice Changes, and
Suggestions for Program Administrators.
Journal of General Internal Medicine
,
34
(10),
2275–2281.
https://doi.org/10.1007/s11606-019-05207-z
Khullar, D., Bond, A. M., Qian, Y., O’Donnell, E., Gans, D. N., & Casalino, L. P. (2021).
Physician practice leaders’ perceptions of Medicare’s Merit-Based Incentive Payment
System (MIPS).
Journal of General Internal Medicine
,
36
(12), 3752–3758.
https://doi.org/10.1007/s11606-021-06758-w
Quality Payment Program. (n.d.).
MIPS overview
.
https://qpp.cms.gov/mips/overview
Rathi, V. K., & McWilliams, J. M. (2019). First-Year report cards from the Merit-Based
Incentive Payment System (MIPS).
JAMA
,
321
(12), 1157.
https://doi.org/10.1001/jama.2019.1295
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