MHA FPX 5068 Assessment 1 Merit-Based Incentives and Daily Operations

Student Name

Capella University

MHA-FPX 5068 Leadership, Management and Meaningful Use of Health Care Technology

Prof. Name

Date

Merit-Based Incentives and Their Impact on Daily Operations

The Merit-Based Incentive Program System (MIPS) was established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to transition the healthcare sector from a fee-for-service model to a value-based payment system. Effective since January 2017, MIPS determines Medicare payment adjustments based on a composite performance score. Eligible clinicians may receive payment bonuses, penalties, or no adjustments depending on their final MIPS score (Centers for Medicare and Medicaid Services [CMS], 2021). The MIPS score is composed of four performance categories: quality, improvement activities, promoting interoperability, and cost. These categories are calculated by CMS using data and activities reported by healthcare organizations (Berdahl et al., 2019).

MIPS consolidates previous quality reporting programs and aims to reduce financial penalties for physicians while increasing potential bonus payments (Rathi, 2019). However, challenges such as the lack of incentives for providers operating under fee-for-service models and difficulties in aligning stakeholders persist. Simplifying quality measures across reimbursement programs could help mitigate these challenges (Eggleton, Liaw, & Bazemore, 2017).

To benefit beneficiaries, quality data must be presented in a user-friendly format, but issues with documentation standards hinder alignment among payers and providers (Berdahl et al., 2019; Johnston et al., 2020). Collaboration between organizations, payers, providers, and quality measurement professionals is essential to address these challenges (Berdahl et al., 2019).

Providers excluded from MIPS eligibility include those participating in Alternative Payment Models (APMs), those with low Medicare beneficiary volume, and those new to Medicare. Meeting MIPS measures requires selecting appropriate measures that align with organizational strengths, investing in MIPS technology, and educating clinicians (Eggleton et al., 2017; Rutherford, 2017).

Failing to meet MIPS measures results in penalties and impacts reimbursement rates. Participation in MIPS offers incentives for performance improvement, while non-participation leads to lower reimbursement rates and missed bonus opportunities (Berdahl et al., 2019; Khullar et al., 2021).

Conclusion

Management strategies should focus on improving MIPS performance by educating clinicians, integrating MIPS requirements into workflows, ensuring accurate clinical documentation, and appointing MIPS champions. These efforts are crucial for maintaining financial stability and enhancing the quality of patient care.

References

Berdahl, C. T., Easterlin, M. C., Ryan, G., 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

Centers for Medicare and Medicaid Services (CMS). (2021). Physician Quality Reporting System (PQRS) overview. CMS.gov. https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/PQRS/downloads/PQRS_overviewfactsheet

Eggleton, K., Liaw, W., & Bazemore, A. (2017). Impact of gaps in merit-based incentive payment system measures on marginalized populations. Annals of Family Medicine, 15(3), 255-257. https://doi.org/10.1370/afm.2075

Horvitz-Lennon, M., Breslau, J., & McConnell, K. J. (2022). Association between the merit-based incentive payment system and access to specialized behavioral health care for Medicare beneficiaries. JAMA Health Forum, 3(3), e220219. https://doi.org/10.1001/jamahealthforum.2022.0219

Johnston, K. J., Wiemken, T. L., Hockenberry, J. M., Figueroa, J. F., & Joynt Maddox, K. E. (2020). Association of clinician health system affiliation with outpatient performance ratings in Medicare merit-based incentive payment system. JAMA, 324(10), 984-992. https://doi.org/10.1001/jama.2020.13136

MHA FPX 5068 Assessment 1 Merit-Based Incentives and Daily Operations

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

Manchikanti, L., Helm II, S., Calodney, A. K., & Hirsch, J. A. (2017). Merit-based incentive payment system: Meaningful changes in the final rule bring cautious optimism. Pain Physician, 20(1), E1-E2. https://doi.org/10.36076/ppj.2018.6.E1

Miller, L. E., Kondamuri, N. S., Xiao, R., & Rathi, V. K. (2022). Otolaryngologist performance in the merit-based incentive payment system in 2018. Otolaryngology-Head and Neck Surgery, 166(5), 858-861. https://doi.org/10.1177/01945998211032896

Rathi, V. K., & McWilliams, J. M. (2019). First-year report card from the merit-based incentive payment system (MIPS): What will be learned and what next? JAMA, 321(12), 1157-1158. https://doi.org/10.1001/jama.2019.1295

MHA FPX 5068 Assessment 1 Merit-Based Incentives and Daily Operations

Rutherford, R. (2017). Thriving under Medicare’s newest pay-for-performance program: Strategies for success with merit-based incentive payment system: Part III. The Journal of Medical Practice Management, 33(1), 51.