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What Risk-Based Payment Models Mean for You – MIPS

As the American healthcare system shifts from quantity-based pricing models to those that incentivize positive outcomes for the patient, clinicians must rethink and reshape their businesses. This is shown by the transition from fee-for-service models with a volume-driven approach to risk-based payment models that expect clinicians to improve the quality of their care while cutting costs.

These models exist in two primary forms: Advanced Payment Models (APMs), such as Accountable Care Organizations, also known as ACOs, and the Merit-based Incentive Payment System, or MIPS. While the two overlap a bit, there are key differences that can affect how much clinicians are paid for the care they provide — and their ability to achieve positive care results. Choosing the right model will become essential as fee-for-service models go by the wayside, but ChartPath can prepare you for the change, whichever one you choose. In this blog we will be focusing on MIPS; check out this blog to review advanced payment model strategies. 

True Risk-Based Payment Models: MIPS

While ACOs distribute risk among the members within the organization, MIPS deals directly with individual clinicians. You can find our MIPS 101 Guide for more information on the inner workings, but these individual risk-based payment models combine a set of criteria where a clinician may be evaluated. It is this evaluation that determines their reimbursement rate.

After adding each metric into its respective categories (Quality, Cost, Improvement Activities, Promoting Interoperability) and weighing them out based on set levels for that year, clinicians are graded on a 0–100 scale. The weight breakdown for each category in 2022 is:

  • Quality: 30%
  • Cost: 30%
  • Promoting Interoperability: 25%
  • Improvement Activities: 15%

In 2022, clinicians that receive a cumulative MIPS score between 75–89% will receive standard Medicare reimbursement rates, but those that fall outside that range will have their rates adjusted. Clinicians achieving a cumulative score higher than 89% are considered to have an "excellent performance." They could receive up to a 9% reimbursement rate increase, while those that fall below 75% have failed to meet quality thresholds and will have their reimbursement rates reduced by 9%.

Bonuses and Benchmarks

Because MIPS relies on a series of metrics to grade the clinicians that participate, it's important to understand which ones have the greatest impact on your score. Some metrics yield larger bonuses than others, as they are considered areas where other clinicians may have difficulty providing high-quality, minimal-cost care. Others are considered so fundamental that to meet these standards is commonplace, and to fail to meet them indicates a problem.

These metrics are known as benchmarks, and those that have been "benchmarked out" can more severely penalize a clinician's score, while meeting them will yield little bonuses. For example, in MIPS category 006," Coronary Artery Disease (CAD): Antiplatelet Therapy," a clinician must score at least 77.78% to get above three points — less if they fall below this benchmark. There are many other benchmarks by which a clinician may be evaluated, but some other examples include:

  • Screening for Osteoporosis for Women Aged 65-85 Years of Age
  • Antidepressant Medication Management
  • Advance Care Plan
  • Breast Cancer Screening
  • Colorectal Cancer Screening
  • Preventive Care and Screening: Influenza Immunization

With so many benchmarks to be evaluated, having an EHR system that can help you select the proper measures can boost your chances of a higher score — and a higher payment.

A Tool for the Job

To help them better navigate their risk-based payment models, ChartPath features a series of functionalities that can help improve their quality metrics. Some of these are:

  • Benchmark monitoring. ChartPath EHR lets clinicians see the thresholds to meet for each benchmark, helping them score well on each metric and view their progress throughout the year. That way, they can maximize their grade to get the largest reimbursement rate possible and avoid costly penalties by falling short.
  • Quality Measures data tracking. Equipped with a "soft stops" feature, clinicians can keep a continual tab on each patient's chart and the quality metrics therein. The "hard stops" feature also lets clinicians know when no further documentation can occur until a specific action has been taken — and both improve quality scores and, subsequently, reimbursement rates.
  • Versatility. From pull-forward tabs that make documenting patients' chronic conditions easier to Top Picks buttons that let clinicians select the most common medical diagnoses, ChartPath has many functionalities that help clinicians work smarter, not harder.
  • Insights. ChartPath's software links ICD-10 codes to HCC categories, giving clinicians better visibility into how they're being scored.

One of the greatest benefits of ChartPath EHR is our end-to-end support. We can guide you through the HCC coding process and help you select the benchmarks that will boost your scores the most, and our fast startup times can help your practice transition to a risk-based payment model in as little as three months. Preparation is essential, though; before making the switch, clinicians should have all of their patients' scores properly weighed by the end of the preceding year in which they enter their ACO or MIPS contract. That's why it's better to start sooner than later.

Make the Switch with ChartPath

Risk-based payment models are designed to meet the goal of every clinician: to give their patients better care. Both ACOs and MIPS take helpful steps toward that end but knowing which to choose can be a challenge. ChartPath journeys with their clients through every step of the journey, ready to help in any way we can. Schedule a demo to see just how you can step into the future of delivering better care.

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