Under the Merit-Based Incentive Payment System, the Centers for Medicare and Medicaid Services evaluates providers on four categories, one of which is cost.
- In 2018, CMS weights the cost category 10 percent (for 2017, cost had a 0 percent weight).
- Cost is the only category you do not have to report for -- CMS automatically pulls data from your Medicare claims to evaluate your cost performance.
- CMS bases your cost score based on a full calendar year performance period (Jan. 1, 2018, to Dec. 31, 2018).
How CMS Measures Cost
CMS evaluates your 2018 cost based on two measures that evaluate Medicare Part A and B claims, similar to how it evaluated providers under the value-based modifier.
- Total per capita cost, per attributed Medicare beneficiary:
- New in 2018, for patient attribution under this measure, CMS looks first for the patient's primary care provider, if the patient has one.
- Costs assigned to the provider who gave the bulk of the patient's care in the calendar year.
- For patients who don't have a primary care provider, CMS could assign costs to an ophthalmologist, if you provided the bulk of the patient's care during the calendar year.
- Medicare spending per beneficiary: No ophthalmologist should see a score on this measure.
- Measures cost related to an inpatient admission (all Part A and Part B claims related to a specific episode of care that involves hospitalization).
- Looks at claims three days before and 30 days after the hospitalization.
For all cost measures, CMS compares your cost to that of similar providers. CMS has not yet specified how it defines similar providers for 2018 (e.g., within the same state).
How CMS Scores You
For each measure, CMS only scores you if you have at least the minimum number of patients attributed to you.
- Total per capita cost: Minimum 20 patients
- Medicare spending per beneficiary: Minimum 35 patients
How these thresholds affect your score:
- If you don't meet a measure's minimum, CMS won't score the measure.
- If, for both measures, you don't meet measure minimum, CMS won't score the cost category at all. Instead, CMS will reweight the quality category 60 percent instead of 50 percent.
If you have enough patients for CMS to score you for a given measure, CMS:
- Will give you a measure score between 1 and 10 points.
- Bases your score on how you compare to other MIPS-eligible clinicians and groups during the performance period (Jan. 1 to Dec. 31 of the performance year).
CMS averages the two measures to calculate your cost category score. If CMS scores you only on one measure (the likely case for most ophthalmologists), that measure score will be your cost category score.
CMS states that cost measures are risk adjusted to account for differences in beneficiary-level risk factors that can affect quality outcomes or medical costs. CMS does this based on risk adjustment algorithms that account for the beneficiary risk score – based on age, sex, disability status, original reason for entitlement (age or disability), Medicaid eligibility, and clinical conditions as measured by Hierarchical Condition Categories (HCCs) – and ESRD status of attributed beneficiaries. The Academy continues to work on risk adjustment that takes into account the additional patient factors that impact patient care.
What You Can Do
To get an idea how you might fare on this category, you can look at a past Quality and Resource Use Report or the upcoming cost report.
The safest way to plan your MIPS reporting: Assume you'll get a 0 score on cost and report other categories accordingly.