MIPS: Medicare’s Strategy to Reimburse for Value Over Volume

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By Phil Stevens, MEd, CPO, FAAOP

It has been roughly ten years since the Institute for Healthcare Improvement released what they described as the Triple Aim framework for improving healthcare.1 The framework has been an ambitious one, entailing the simultaneous pursuits of improving the patient's healthcare experience, improving the health of populations, and reducing the per capita cost of healthcare.

Within this broader framework, healthcare has begun to transition from its legacy model of fee-for-service, a volume-based reimbursement model in which clinicians are incentivized to provide higher quantities of care, to fee-for-value, in which incentives are transitioned to the provision of higher qualities of care.

The latest strategy from the Centers for Medicare & Medicaid Services (CMS) to facilitate this transition kicked off among physicians in 2017, the Merit-Based Incentive Payment System (MIPS). This article provides an overview of the MIPS program and its elements, describes its expected roll-out and expansion, and discusses possible impacts on future reimbursement in O&P care.

What Is MIPS?

Unfortunately, understanding MIPS is not easy; several companies and agencies are in place to help physician groups navigate its processes. The overarching goals of the Quality Payment Program are relatively straightforward: "Modernizing Medicare to provide better care and smarter spending for a healthier America."2 If that sounds familiar it's because it's a restatement of the Triple Aim. But it gets more complex.

For 2017, the threshold for inclusion in the Quality Payment Program is relatively low. Physicians, physician assistants, nurse practitioners, clinical nurse specialists, or certified registered nurse anesthetists who bill Medicare more than $30,000 annually in Part B charges and provide care for more than 100 Medicare patients are considered to be in the program.2 However, only healthcare professionals in the listed categories are currently included in the program.

For these professionals, the performance period for MIPs, opened on January 1, 2017, and closed on December 31, 2017. During that window, professionals were asked to record "quality data" and "how you used technology to support your practice."2 That data is due to Medicare by March 31. Following submission, Medicare has promised to provide "feedback about your performance" in 2018. To do so, Medicare will aggregate the quality data to determine a performance threshold for various encounter types. Fiscal adjustments to reimbursement for 2017 performance will be assessed against that threshold in 2019.2

Those who chose not to participate in the program will be hit with a negative 4 percent payment adjustment. Those who have submitted "a minimum amount of 2017 data to Medicare" will avoid a downward payment adjustment (i.e., no penalty and no reward). Those who have submitted at least 90 days of the requested 2017 data to Medicare begin to earn positive payment adjustments.2 As the program matures, the penalties and payoffs increase, with the ±4 percent in 2019 increasing to ±5 percent in 2020, ±7 percent in 2021, and ±9 percent in 2022.2 In addition, there is an "exceptional performance bonus that can increase up to 10 percent for the highest performers who exceed an "exceptional performance threshold" in their number of MIP points.6

As described, the 2017 data will be used to determine the "performance threshold" for 2019 payouts and penalties. This threshold will be redetermined annually as the average of the MIPS scores among eligible clinicians in the prior performance period. As a testament to the long-term intent of the initiative, these thresholds are expected to increase year over year as the average performance values increase and lower performers eventually drop out of Medicare (and MIPS).6

Quality Measures

Positive payment adjustments are based on the submission of "evidence-based" and "practice-specific quality data," demonstrating that you provided "high-quality, efficient care supported by technology."3 Reporting requirements currently entail three domains: quality, improvement activities, and advancing care information. A fourth category of cost is slated for inclusion in 2018.3

Sixty percent of MIPS performance is based on reporting of quality measures. Practitioners are instructed to select a set of quality measures that best fit their practices, including at least one outcome measure. The qpp.cms.gov website currently lists 271 measures ranging from "Acute Otitis External: Systematic Antimicrobial Therapy – Avoidance of Inappropriate Use," to "Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents.3"

Many of these quality measures are simply the documentation of the performance of appropriate evaluations or screenings. For example, under Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear, participating clinicians must report the "percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing."

However, others require the administration of predetermined outcome measures at the beginning and conclusion of an episode of care, tracking the relative improvements experienced by the patients of a clinician or clinic on a target outcome. An example is seen in the Functional Status Change for Patients with Foot or Ankle Impairments. Here, participants 14 years or older with foot and ankle impairments are assessed using the National Quality Foundation (NQF) 0424, conveniently titled Functional Status Change for Patients with Foot or Ankle Impairment. The instrument is a self-report questionnaire in which subjects rate the amount of difficulty they associate with the performance of daily tasks such as household ambulation, lifting objects, light- and heavy-duty household activities, community ambulation, and navigating stairs.

Then things get a bit more complicated. Any changes that a patient reports aftertreatment are risk adjusted according to those patient characteristics that are known to have an effect on this outcome. After taking those characteristics into account through risk adjustment, the functional impact of the physician's care is measured at the individual patient level, at the physician level, and at the clinic level to assess the quality of the care that's being provided.4

Physicians First, Others Will Follow

The launch of MIPS was limited to the narrow scope of clinicians identified earlier, with other disciplines such as physical, occupational, and speech therapists slated for inclusion in 2019. During the interim period, many therapists are eager to participate in MIPS on a voluntary basis. WebPT's president, Heidi Jannenga, PT, DPT, ATC/L, was quoted in a blog post on this topic recommending that therapists "continue building our data stores by committing to collecting meaningful outcomes data."5

The same post summarizes additional reasons for voluntary participation from therapists leading up to their 2019 formal inclusion. These include maintaining the data-reporting habits of prior Medicare requirements, learning the ins and outs of MIPS reporting in a no-pressure environment (no negative payment adjustments), and facilitating increased confidence in participating in MIPS once it become mandatory.5 Further, CMS has indicated its intention to provide feedback to those who voluntarily participate in the program during what would amount to a trial period.5

Scores Will Be Shared

The WebPT post goes on to explain that in addition to the direct fiscal adjustments to Medicare reimbursements, there could be other financial repercussions associated with the outcomes of your care.5 According to SA Ignite, a company specializing in the execution and management of value-based healthcare programs, "MIPS will publish each eligible clinician's annual final score and the scores for each MIPS performance category within approximately 12 months after the end of the relative performance year." The SA Ignite website explains, "For the first time, consumers will be able to see their clinicians rated on a scale of 0 to 100 and how their clinicians compare to peers nationally."6

What's more, if you change jobs, your quality scores will follow you as "CMS binds the MIPS score to the clinician for each performance year, so that if the clinician changes organization before the associated payment year (two years after the performance year), the clinician brings along his or her MIPS score and the associated Part B adjustment to the new organization…. Each MIPS score thereby becomes a central and inextricable part of a clinician's profile and public reputation."6


Potential Impact on O&P

While there has been no formal mention of orthotists or prosthetists in the MIPS program, the program conveys the emphasis that CMS is placing on quality over quantity. It is not inconceivable to forecast a time in the near future where prosthetists may be asked to select a small number of quality measures from a menu of approved measures, collect these as a standard of care at the beginning and end of treatment, and report observed changes to the funding agency. The agency would adjust the outcome scores according to known risks, considering amputation level, amputation etiologies, or certain comorbid health conditions. The scores of an individual prosthetist or prosthetic clinic would then be compared against those of their peers, with patients and payers alike having access to those quality scores. Reimbursement adjustments, in the form of either bonuses or penalties, would eventually be assessed based on the comparative quality of care provided by a given clinician or facility.


Phil Stevens, MEd, CPO, FAAOP, is in clinical practice with Hanger Clinic, Salt Lake City. He can be contacted at philmstevens@hotmail.com.



  1. Berwick, D. M., T. W. Nolan, and J. Whittington. 2008. The Triple Aim: Care, Health and Cost. Health Affairs, 27(3):759-69.

  2. https://qpp.cms.gov

  3. https://qpp.cms.gov/mips/overview

  4. https://qpp.cms.gov/mipsquality-measures

  5. McDermott, Erica. "MIPS FAQ for PTs, OTs, and SLPs," WebPT, January 25, 2017, https://www.webpt.com/blog/post/mips-faq-for-pts-ots-and-slps.

  6. www.saignite.com/industry-expertise/quality-payment-program/mips-education/10-faqs-about-mips/