What’s proper weighting for MIPS’ cost-performance category? 0%

Tanya Albert Henry , Contributing News Writer

AMA News Wire

What’s proper weighting for MIPS’ cost-performance category? 0%

Jan 11, 2024

On top of the 3.37% across-the-board Medicare physician pay cut that took effect Jan. 1, some physicians are facing additional cuts in their 2024 pay due to the cost-performance category in the flawed Merit-based Incentive Payment System (MIPS).

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The AMA sent an initial letter (PDF) to Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure in October asking the agency to reweight that category to zero percent of the score to nullify “the negative impact of the problematic measures” and to correct the problems “before they negatively impact payment and patient access to care.” Since then, the AMA has heard from physicians about additional problems with the cost measures and sent another letter (PDF) last month documenting ongoing concerns and reiterating its call to exclude cost measures from MIPS scores.

Now, the 2022 MIPS cost-performance category accounts for 30% of the final scores Medicare used to determine what adjustments the agency made to physicians’ 2024 payments. However, physicians didn’t have any way to anticipate, monitor and improve their score in the cost-performance category because CMS didn’t show physicians their 2022 data for their attributed measures, patients and observed costs until August 2023. That’s more than eight months after the performance period ended.

“By failing to share timely data, CMS is subverting the goal of the cost measures and instead seeding distrust in the measures and CMS’ objective with the MIPS cost performance category. Are the cost measures meant to reduce unnecessary costs for Medicare beneficiaries and for the Medicare program or are they simply meant to penalize physicians?” AMA Executive Vice President and CEO James L. Madara, MD, wrote in the October letter.

The AMA is calling on CMS to study and reevaluate the cost-performance category—which the AMA addressed in an earlier letter to CMS—and all administrative claims measures. Overall, MIPS payment adjustments have the potential to cut a physician’s Medicare payment by up to 9% on top of the across-the-board cuts.

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Real-world unintended consequences

The AMA has heard “multiple accounts of unintended negative consequences and have serious concerns that the cost measures are not operating as intended.”

Among them:

  • Group practices being measured on the Total Per Capita Cost (TPCC) measure even though they are excluded from the measure due to qualified health professionals (QHPs) in their group practice billing Medicare directly.
  • An ophthalmologist receiving a near-perfect score on the cataract surgery measure due to episodes without operating room expenses, leading to a distorted benchmark for physicians with accurate billing.
  • An internist who scored very poorly on the asthma/chronic obstructive pulmonary disease cost measure despite performing well on the TPCC measure. Of the 20 patients the physician had attributed to the measure in 2022, one patient had sepsis that had an outsized impact on the physician’s score.
  • A large multispecialty physician practice that scored poorly on the joint replacement episode-based cost measures despite being a high performer in the Bundled Payments for Care Improvement advanced alternative payment model.
  • Rheumatology practices performing poorly on the TPCC measures, likely because of high Part B drug costs.

We need your help

Become a member and help the AMA fight to protect physician payment and patients’ access to care.

Explore the AMA's Medicare Basics series, which provides an in-depth look at important aspects of the Medicare physician payment system—including MIPS. Through straightforward explanations, policymakers and physician advocates can learn about key elements of the payment system and why they are in need of reform.  

The AMA has had multiple conversations with CMS officials about this issue. CMS also followed up with a response letter that failed to address the concerns that the AMA has raised about the cost measures and MIPS scoring. The AMA is continuing to communicate physicians’ concerns about the 2022 cost measures and advocating relief from unfair penalties for physicians

Learn how you can take part in the fight to change Medicare on behalf of your patients and practices at the AMA's Fix Medicare Now website.

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