As laid out in the 2019 MACRA final rule*, one of the ways CMS hopes to expand participation options in the program’s third year is by offering certain facility-based clinicians, if they participate as a group, the option to use facility-based Quality and Cost performance measures. CMS expects to release a facility-based scoring preview for this option, which does not require any data submission, in Q1 of 2019. In today’s blog, we’ll take an in-depth look at the details of facility-based scoring and how it will be applied.
For facility-based scoring, CMS will use the measure set for the fiscal year Hospital Value-Based Purchasing (VBP) program that begins during the applicable MIPS performance period. The performance of a MIPS eligible clinician would be individually applicable if that clinician furnishes 75% or more of their covered professional services in an inpatient hospital (identified by POS code 21), an on-campus outpatient hospital (POS 22), or an emergency room (POS 23), based on claims for a period prior to the performance period. The clinician must have at least a single service billed with the POS code used for the inpatient hospital or emergency room, and can be attributed to a facility with a Hospital VBP Program score for the applicable Period.
A facility-based group is defined as one in which 75% or more of the MIPS eligible clinician NPIs billing under the group’s TIN are eligible for facility-based measurement as individuals.
A facility-based clinician will be attributed to the hospital at which they provide services to the most Medicare patients. A facility-based group will be attributed to the hospital at which a plurality of its facility-based clinicians are attributed. In the case that an equal number of Medicare beneficiaries is treated at more than one facility, the value based purchasing score for the highest scoring facility will be used.
A clinician is not eligible for facility based measurement if they are unable to identify a facility with a VBP score to attribute the clinician’s performance. In this case, the clinician will have to participate in MIPS via other methods.
For clinicians and groups who are eligible for facility-based measurement and who would benefit by having a higher combined Quality and Cost score, facility-based measurement will be automatically applied. No data submission requirements exist for the Quality and Cost performance categories for individual clinicians and groups in facility-based measurement, so in order to fall under facility-based measurement, an individual or group must submit data in the Improvement Activities or Promoting Interoperability performance categories.
Benchmarks for facility-based measurement will be those that are adopted under the Hospital VBP program of the facility for the year specified.
Assigning MIPS Category Scores
CMS will determine both Quality and Cost performance category scores for facility-based measurement via the percentile performance of the facility determined in the VBP program for the specified year. CMS will award a score associated with that same percentile performance in the MIPS Quality and Cost performance category scores for those clinicians who are not scored through facility-based measurement. Since improvement is already captured in the Hospital VBP Program Total Performance Score, CMS requires no additional improvement scoring for facility based measurement.
Some hospitals do not receive a Total Performance Score in a given year in the Hospital VBP Program, whether due to insufficient quality measure data, failure to meet requirements under the Hospital IQR Program, or for other reasons. In these cases, facility-based clinicians would be required to participate in MIPS via another method since CMS would be unable to calculate a facility-based score based on the hospital’s performance.
*This article is based on, and takes certain clauses verbatim from, the Quality Payment Program Year 3 Final Rule Overview.