MACRA for Busy Docs: 12 Things to Know

Leigh Page

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September 07, 2016

In This Article

Comparison and Competition

10. You'll Be Competing Against Your Peers

MIPS penalties and bonuses are budget-neutral: Penalty payments from low performers pay for the bonuses for high performers. This means that about one half of ECs will get a penalty, and the other half will get a bonus.

Thus, if most of your colleagues are performing at a high level, "you could pay a penalty even if your performance is simply good," Dr Edney says.

This is unlikely to happen, though, in the introduction of MIPS. That's because many clinicians have been refusing to cooperate with current reporting programs and are getting failing grades, and this phenomenon is expected to continue into MIPS. In a budget-neutral system, these low-performing physicians would make it easier for everyone else to perform better and perhaps earn a bonus.

How bad is the current dropout rate? In 2015, CMS reported[6] that only about one half of eligible professionals participated in PQRS in 2013. Also in 2015, more than 257,000 eligible professionals received a 1% decrease in their Medicare payments because they failed to meet MU standards in 2014, CMS reported in a press conference.[7]

11. High Performers Can Earn Big Bonuses

With so many clinicians dropping out of reporting programs, those who do very well in MIPS could make a whole lot of money in bonuses. Bonuses are not being paid in PQRS and MU, which rely only on penalties, but they are a central feature of MIPS.

The pot of money from penalties goes to bonuses. The minimum amount of bonuses will rise at the same gradations that penalties will rise—starting at 4% in 2019, then going to 5% in 2020, 7% in 2021, and 9% in 2022 and beyond.

However, the proposed rule allows bonus amounts to be as much as three times higher than these figures. Patrick says this can happen even in a zero-sum payment system. With so many refusing to report, clinicians will bunch up around the maximum penalty, outnumbering the clinicians getting the highest scores and leaving then with bigger bonuses, she says.

But that's not all of the extra bonus payments that will be showered on high achievers. Clinicians with MIPS composite scores in the top 25% will also receive an "exceptional performance bonus" of up to 10% of their Medicare Part B reimbursement, to be taken from an extra bonus pool of $500 million a year between 2019 and 2025.

Indeed, the total bonus payment in MIPS could easily exceed the 5% bonus payment that QPs get in advanced APMs, says Jonathan Burroughs, MD, a healthcare consultant in New Hampshire. This phenomenon might prompt some QPs to dump the advanced APM program and enter MIPS, he says.

In any case, the rising bonuses and penalties "will create a widening gap between the haves and have-nots," Dr Burroughs predicts. "Low performers will have to pay a lot of money in penalties, and the money will go into the pockets of the high performers."

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