understanding the 2019 mips cost category...medicare spending per beneficiary measure (mspb) part a...

Understanding the 2019 MIPS Cost Category

Beth Hickerson, Medical Advantage Group

Bruce Maki, Altarum

Value Driven. Health Care. Solutions.

COST CATEGORY OVERVIEW

Cost Category

3Value Driven. Health Care. Solutions.

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


Cost Measure Adjustment Processes

Payment Standardization

Annualization

Specialty Standardization

Risk Adjustment

Attribution



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



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



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.



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



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?


TOTAL PER CAPITA COST (TPCC)

TPCC Overview


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


TPCC Attribution


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


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


– Durable medical equipment,

prosthetics, orthotics, and supplies

(DMEPOS)

– Non-institutional physician/supplier

claims (Medicare Part B Carrier

claims)

MSPB Attribution


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


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)


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


COST CATEGORY SCORING

Scoring Methodology


Each of the 10 Cost measures have a maximum of 10 possible achievement

points.

Cost Scoring Example


FACILITY-BASED SCORING

Facility-based Scoring Eligibility


Facility-based Scoring Attribution


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

https://qpp-cm-prod-content.s3.amazonaws.com/uploads/454/2019 Facility-Based Measurement Fact Sheet_Final.pdf

COST CATEGORY FEEDBACK

Print Your Entire Feedback Report


Access Cost-specific Feedback


Expand Measures for Additional Info


Measure Details - TPCC


National Distribution - TPCC


2018 TPCC Benchmark Range = $10,082 to $79,929

Measures Details - MSPB


National Distribution - MSPB


2018 MSPB Benchmark Range = $19,511 to $43,284

Total Cost Score Calculation


SUPPLEMENTAL DATA

Download Your Beneficiary Level Data


Beneficiary Data Spreadsheet – TPCC


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?



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



Sort by Emergency Services to identify patients who

might be inappropriately using the Emergency

Department

Consider educating these patients on after-hours care

options


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


– 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


Beneficiary Data Spreadsheet – MSPB

Sort by Episode Cost or Index Admission or

Readmission

Can you identify factors that may have attributed to

Readmission?


MSPB Review - Example

Large specialty practice evaluated their MSPB

attribution using EHR information and found the

following:

– 320 beneficiaries attributed to TIN


– Reviewed the charts for top 20% (24 patients)

– Only 2 were active established patients before their admission

– No common chronic diagnosis


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.


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?



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



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


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


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…


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


https://qpp-cm-prod-content.s3.amazonaws.com/uploads/559/2019 MIPS Cost User Guide.pdf

https://qpp-cm-prod-content.s3.amazonaws.com/uploads/345/2019+Cost+Measure+Information+Forms.zip

Poll Question

–


THANK YOU!Questions?

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understanding the 2019 mips cost category...medicare spending per beneficiary measure (mspb) part a...

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