Nailing PQRS in 2016 is the Best Way to Prepare for MIPS

Does MACRA (Medicare Access or CHIP Authorization Act) or MIPS (Merit-based Incentive Payment System) sound daunting? If you’re like most health systems you’ll answer with a gulping yes.

Before I answer your question about the best way to prepare for MIPS, let’s just make sure we are on the same page by answering the following:

What exactly is MIPS?

Starting CY2017, MIPS will annually measure Medicare Part B providers in four performance categories to derive a “MIPS score” (0 to 100), which can significantly change a provider’s Medicare reimbursement in each payment year. The performance categories and point allocations for the CY2017 performance year are 50 points for quality (PQRS/VBM), 25 points for meaningful use, 15 points for clinical practice improvement, and 10 points for resource use.

The MIPS final rule (due late this year) will determine how points are earned within each component.

The financial impacts of the MIPS scoring system can be significant. The following diagram shows how it works:

Screen Shot 2016-04-30 at 1.04.20 AM


Each performance year (say 2017, corresponding to the Payment Year 2019 in the diagram above), CMS sets a “performance threshold” (PT) number of points at which a provider earning PT points receives 0% adjustment to their Medicare Part B payments.

If PT = 50, then only a provider earning exactly 50 points will get 0% payment adjustment. A provider earning 51 points earns an incentive, whereas one achieving only 49 points will be assessed a penalty. These payment adjustments increase in size linearly as the point value further deviates from the PT value of 50 until maximum incentives are penalties are reached.

Furthermore, as can be seen in the diagram, the maximum base payment adjustment can range up to a 9% x 3.0 = 27% incentive or down to a -9% penalty.

Medicare is able to reward winners so much more than losers because the entire MIPS program is designed to be budget neutral, whereby the national incentive pool is set equal to the national penalties applies. Since there are anticipated to be more losers than winners, winners can reap substantial financial rewards under MIPS.

The performance threshold PT is determined annually as the mean or median of the MIPS scores for all EPs in a prior period as selected by CMS. For the initial two payment years (2019 and 2020), the PT will not be based on historical MIPS scores but rather on a combination of historical performance on measures and activities related to PQRS, MU, VBM, and possibly other factors as determined by CMS.

Now there is some additional nuance that isn’t covered above, such as alternate payment models. In the coming weeks we’ll detail all fo the nuance and diagram the most optimal path to take. Now on to the pressing question:

How can I prepare now for MIPS?

Nail PQRS today with a monitoring model. Some readers may be reading this and saying to themselves, “well, this seems simple.” All I need to do is nail PQRS, I have been doing that for years now.” But, have you been monitoring and trending it in such a way where you know how things are progressing at any given point? MIPS is very much focused on improvement and if you’re not monitoring PQRS for improvement now, how will you do it when you have many different clinical improvement measure that need to be tracked? If you couldn’t read into where  CMS is trying to take MIPS then let me say it simply — MIPS is the beginning of the era of improving quality measures while also lowering the cost of healthcare (two of the three triple aims).

Equation’s PQRS Offering

Sound daunting? It shouldn’t be, not if you have Equation helping you. In the coming weeks Equation will be releasing more details about how it will help health systems nail MIPS. A major part of preparing for MIPS is utilizing Equation to calculate PQRS measures now and then to utilize that data to begin tracking progress towards hitting MIPS. Keep your ear to this blog because we will announce soon in greater detail how we can help you best prepare for MIPS.

If you are interested to have Equation calculate and submit PQRS measures then please reach out to Mike Romney at 801.783.4100 or email him at

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