Risk considerations for innovative products: A case study of the long-term care insurance industry
This report explores key risks and considerations for product innovation using the long-term care insurance industry as a case study.
What happened in the first year of MIPS reporting?
Starting in 2019, many clinicians performing services for Original Medicare patients will have their payments adjusted based on quality and other metrics from 2017. The Merit-Based Incentive Payment System (MIPS) is a revenue-neutral program that will adjust Part B payments, with a maximum -4% penalty in 2019.
MIPS was passed into law as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)1,2. For 2017 dates of service, eligible clinicians (ECs) recorded and submitted measurements across three key areas: quality, improvement activities, and advancing care information (now called promoting interoperability)3. Based on these areas, ECs received a final score between 0 and 100, which then affects their payment rates for Medicare Part B services in 2019. The program is revenue-neutral, meaning the bonus payments will be adjusted based on the level of penalties.
The following interactive charts are designed to allow users to explore some of the results of the 2017 reporting.
Nationwide4, the average score was 65.1 (271,522 submitting ECs) points out of a possible 100, substantially exceeding the minimum score necessary to avoid a payment penalty in 2019. North Dakota had the highest average score at 85.7 (934 submitting ECs), while Rhode Island had the lowest score at 46.8 (799 submitting ECs).
The first chart shows a national map shading states by their average final score (a darker color equates to a higher score), based on the practice location of ECs reporting under either the group or individual methods for data submission to CMS. Hovering over a state will show the average score across all ECs practicing in the state, as well as the number of ECs.
Based on the 2017 final score, ECs receive either a bonus or penalty to their 2019 Medicare Part B payments under Original Medicare. For 2019 payments, CMS announced in late 2018 that the adjustments would be as follows5:
The next chart shows the distribution of ECs into these four categories, separately for ECs submitting their results individually under their national provider identifier (NPI) and as a group under the same tax identification number (TIN). On a nationwide basis, many groups were able to submit exceptional results, achieving the highest levels of payment bonus. Compared to group submissions, fewer individually submitting ECs landed in the exceptional category, but there were still a substantial number. Conversely, while few ECs received zero points, more of those ECs submitted as groups rather than as individuals. There were 726 individually-submitting ECs and 30,082 group-submitting ECs receiving the maximum penalty with a score of zero.
For an even more detailed look, the subsequent chart shows distributions by state. In general the story is similar across states, though a few stand out as being particularly thorough in at least minimal submissions (and therefore experiencing few penalties), such as Georgia, Florida, and South Carolina. These two charts are linked, so clicking on an item in one chart can change the focus on all the charts. For example, try clicking a state to see the distribution on scores just for that state.
Overall, these results suggest that most ECs were able to successfully submit some level of reporting under the MIPS program, and frequently at the highest levels of results. As the program matures, CMS has indicated that they will revise the score thresholds described above. For 2018 dates of service and metrics, for example, the breakeven threshold score has been set at 15 points7, substantially higher than the 3 points for 2017. Without the protection of the Pick Your Pace program, and with the increased breakeven threshold score, eligible clinicians will face a more significant hurdle to avoid payment penalties in 2020 and beyond.
Further, metrics and scoring will change to account for large numbers of ECs reporting maximal scores in the same category (called “topping out”). This could reduce the number of ECs receiving exceptional bonuses in the future.
As the program evolves, ECs subject to the reporting requirements will need to maintain and enhance their reporting and submission procedures to remain competitive in the scoring process to keep their Part B payment levels from dipping.