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Understanding the 2019 MIPS Cost Category
Beth Hickerson, Medical Advantage Group
Bruce Maki, Altarum
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COST CATEGORY OVERVIEW
Cost Category
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No reporting required – data comes from Medicare administrative
claims
Weighted at 15% of MIPS Final Score in 2019
Weighting will continue to increase each year until it hits 30% in
2022
Cost Measures
Cost scoring will be based on:
Total per Capita Cost (TPCC) Part A + Part B for the performance year
Minimum 20 attributed patients
Medicare Spending per Beneficiary Measure (MSPB) Part A + Part B for a hospital admission
Minimum 35 attributed patients
8 Episode-Based Measures All costs clinically related to designated procedures or acute
inpatient medical conditions
Minimum 10 (procedures)/20 (acute inpatient conditions)
attributed patients
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Cost Measure Adjustment Processes
Payment Standardization
Annualization
Specialty Standardization
Risk Adjustment
Attribution
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Cost Measure Adjustment Processes
Payment Standardization – the method that
normalizes Medicare payments to account for
factors unrelated to the provision of care,
such as:
Geographic rate differences
Add-on payments for medical education
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Cost Measure Adjustment Processes
Annualization – the method for calculating
estimated expenses for a full year of Medicare
payments when patients are only covered by
Medicare for a partial year
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Cost Measure Adjustment Processes
Specialty Standardization – the method for
normalizing cost across specialties based on the
clinical complexity of patients commonly treated
by each specialty
Ex: An oncologist generally treats more complex
patients than a primary care provider.
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Cost Measure Adjustment Processes
Risk-adjustment – the method for “normalizing”
clinical complexity across patients so that cost
can be compared across providers. Can include:
CMS Hierarchical Condition Category (CMS-HCC)
indicators
Recent long-term care status
End stage renal disease (ESRD) status
Medicare Severity Diagnosis-Related Group (MS-
DRG) codes
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Cost Measure Adjustment Processes
Attribution – the method that determines which
individual physician or group each patient will be
assigned to for Cost comparison
Ex: If a patient sees 5 providers in one year, which
provider is responsible for the patient’s cost of
care?
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TOTAL PER CAPITA COST (TPCC)
TPCC Overview
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Numerator = Sum of the Medicare Parts A & B costs
incurred by all beneficiaries attributed to an individual
clinician (TIN-NPI) or a group (TIN)
Denominator = Number of Medicare beneficiaries who
are attributed to an individual clinician (TIN-NPI) or a
group (TIN) during the performance year
Assesses the total Medicare Parts A & B costs for a
beneficiary during the performance year by calculating the
risk-adjusted, per capita costs for attributed beneficiaries.
Requires a minimum of 20 attributed patients.
TPCC Attribution
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TPCC Attribution
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Who is considered Primary Care?
MEDICARE SPENDING PER BENEFICIARY
(MSPB)
MSPB Overview
Assesses total Medicare Parts A & B costs incurred by a
single beneficiary immediately prior to, during, and 30 days
after a qualifying event, and compares observed costs to
expected costs.
Requires a minimum of 35 attributed patients
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MSPB Expected vs Observed Costs
Observed costs – actual billed charges for the following
claim types
– Inpatient hospital
– Outpatient
– Skilled nursing facility
– Home health
– Hospice
Expected costs – based on the clinical condition or
procedure that triggered the episode, and include factors
that influence cost but are not directly related to patient care
– e.g. age, enrollment status, and comorbidities, HCCs
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– Durable medical equipment,
prosthetics, orthotics, and supplies
(DMEPOS)
– Non-institutional physician/supplier
claims (Medicare Part B Carrier
claims)
MSPB Attribution
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Each episode is attributed to a single MIPS eligible
clinician (TIN-NPI) who billed the largest amount of
Medicare Part B claims (dollar amount of Medicare-
allowed charges) during the period between index
admission and discharge date, including: Part B services provided on the admission date and in a hospital
setting with place of service (POS) restricted to hospital inpatient,
outpatient, or emergency room
Part B services provided during the index hospital stay, regardless of
POS
Part B services provided on the discharge date with a POS restricted
to inpatient hospital
EPISODE-BASED MEASURES
Episode-based Measures Overview
Assess the cost of care that is clinically related to initial
treatment of a patient and provided during an episode’s
time frame.
Two categories:
Procedural episode group – requires minimum of 10
attributed patients
Acute inpatient medical condition group – requires
minimum of 20 attributed patients
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Episode-based Measures
Routine Cataract Removal
with IOL Implantation
Knee Arthroplasty
Elective Outpatient
Percutaneous Coronary
Intervention (PCI)
Lower Extremity Chronic
Critical Limb Ischemia
Screening/Surveillance
Colonoscopy
Intracranial Hemorrhage or
Cerebral Infarction
Simple Pneumonia with
Hospitalization
ST-Elevation Myocardial
Infarction (STEMI) with
Percutaneous Coronary
Intervention (PCI)
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Episode-based Measure Attribution
Acute inpatient medical condition episodes are
attributed to each EC who bills inpatient evaluation and
management (E&M) claim lines during a trigger
inpatient hospitalization under a TIN that renders at
least 30% of the inpatient E&M claim lines in that
hospitalization
Procedural episode are attributed to each EC who
renders a triggering service as identified by
HCPCS/CPT procedure codes
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COST CATEGORY SCORING
Scoring Methodology
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Each of the 10 Cost measures have a maximum of 10 possible achievement
points.
Cost Scoring Example
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FACILITY-BASED SCORING
Facility-based Scoring Eligibility
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Facility-based Scoring Attribution
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Learn more: 2019 Facility-based Measurement Fact Sheet
https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/454/2019%20Facility-
Based%20Measurement%20Fact%20Sheet_Final.pdf
COST CATEGORY FEEDBACK
Print Your Entire Feedback Report
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Access Cost-specific Feedback
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Expand Measures for Additional Info
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Measure Details - TPCC
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National Distribution - TPCC
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2018 TPCC Benchmark Range = $10,082 to $79,929
Measures Details - MSPB
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National Distribution - MSPB
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2018 MSPB Benchmark Range = $19,511 to $43,284
Total Cost Score Calculation
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SUPPLEMENTAL DATA
Download Your Beneficiary Level Data
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Beneficiary Data Spreadsheet – TPCC
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Beneficiary Data Spreadsheet – TPCC
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Sort to Prioritize your Research
Sort by Total Scaled Cost to identify highest cost
patients and categories
Look up highest cost patients in EHR – can you identify
factors that may have contributed to patient’s high
cost?
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Sort to Prioritize your Research
Sort by HCC Percentile Ranking to identify high-risk
patients who are more likely to incur high cost
Consider flagging these patients in your system as
high-risk or enrolling them in care management
services
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Sort to Prioritize your Research
Sort by Emergency Services to identify patients who
might be inappropriately using the Emergency
Department
Consider educating these patients on after-hours care
options
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TPCC Review - Example
Large specialty practice evaluated their TPCC
attribution using EHR information and found the
following:
– 201 beneficiaries attributed to TIN
– 10 patients accounted for 55% of the total attributed costs
– 7 patients were hospitalized OR in rehab OR in an extended-care
facility, 1 patient was on dialysis for End State Renal Disease
– There was no common diagnosis for the top 10 cost patients
– 45 patients accounted for 90% of the total attributed costs
– Approximately 40% of attributed beneficiaries were
referred from the local Air Force Base or VA clinic
– Many attributed patients were low-cost and positively
influenced the group’s Cost score
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Beneficiary Data Spreadsheet – MSPB
Sort by Episode Cost or Index Admission or
Readmission
Can you identify factors that may have attributed to
Readmission?
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MSPB Review - Example
Large specialty practice evaluated their MSPB
attribution using EHR information and found the
following:
– 320 beneficiaries attributed to TIN
– 77 patients accounted for 50% of the total attributed costs
– Reviewed the charts for top 20% (24 patients)
– Only 2 were active established patients before their admission
– No common chronic diagnosis
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IMPROVING YOUR COST SCORE
Cost Containment is a Marathon!
Efforts implemented now will have little to no impact on
your 2019 Cost score. You are planning for the future.
Your 2018 attributed patients will not necessarily be
your 2019 attributed patients.
Improving your systems/processes related to Cost
factors is more important than addressing individual
patients.
Episode-based Cost reductions may be easier to
achieve than TPCC or MSPB reductions.
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Strategies to Reduce Cost
Understand YOUR Cost measures and attributed
patients
– Do a small number of patients account for a large % of
total cost?
– Are there common factors among your highest cost
attributed patients?
– Common chronic conditions
– Common co-morbidities
– Socio-economic factors
– If your patients go to multiple hospitals, does
one facility account for more of your MSPB
attributed patients?
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Strategies to Reduce Cost
Avoid unnecessary hospitalizations for your patients
• Implement 24/7 access to clinicians for urgent patient issues
• Consider expanding access outside of normal business hours
• Open same-day appointments on Friday afternoons
• Implement care management strategies for your highest risk
patients
Educate your billers, coders, and providers
on Hierarchical Condition Category coding
• Proper coding ensures that “expected costs” align
with patient risk factors
• Contact your national specialty association
for guidance and education
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Strategies to Reduce Cost
Make the most of your EHR
• Seek vendor-supplied or third-party consultants to optimize your
EHR
o Activate HCC coding alerts and functions
o Build customized care gap reports for population-level
monitoring
o Utilize built-in test and lab tracking tools
o Improve use of patient portal communication so that patients
can reach you more easily
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COST IN 2020 AND BEYOND
Year 4 Proposed Cost Changes
Attribution would be different for individuals and for
groups
Some specialties who primarily deliver certain non-
primary care services would be excluded from TPCC
attribution
MSBP attribution methodology would be different for
surgical and medical patients
10 new episode-based measures
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10 New Episode-based Measures for 2020
1. Acute Kidney Injury
Requiring New Inpatient
Dialysis
2. Inpatient Chronic COPD
Exacerbation
3. Lower Gastrointestinal
Hemorrhage
4. Renal or Ureteral Stone
Surgical Treatment
5. Non-Emergent Coronary
Artery Bypass Graft
(CABG)
6. Elective Primary Hip
Arthroplasty
7. Hemodialysis Access
Creation
8. Femoral or Inguinal
Hernia Repair
9. Lumbar Spine Fusion for
Degenerative Disease,
1-3 Levels
10.Lumpectomy Partial
Mastectomy, Simple
Mastectomy
MIPS Weighting in PY 2022…
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30%
25%
15%
30%
Quality PI IA Cost
REFERENCES/RESOURCES
Additional Resources
MIPS: Participating in the Cost Performance Category
in the 2019 Performance Year
– https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/559/2019%20MIPS
%20Cost%20User%20Guide.pdf
2019 Cost Measure Information Forms
– https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/345/2019+Cost+Me
asure+Information+Forms.zip
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Poll Question
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