American College of Emergency Physicians
2023 MIPS Performance Year: What’s New and How to Get Prepared!
2023 will be a big year for the Merit-based Incentive Payment System (MIPS)!
The Quality Payment Program (QPP), established by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, includes two tracks: MIPS and Advanced Alternative Payment Models (APMs). MIPS includes four performance categories: Quality, Cost, Improvement Activities, and Promoting Interoperability (formerly Meaningful Use). Performance on these four categories (which are weighted) roll up into an overall score that translates to an upward, downward, or neutral payment adjustment that providers receive two years after the performance period (for example, performance in 2023 will impact Medicare payments in 2025). Those who successfully participate in Advanced APMs can receive a five percent bonus and are exempt from MIPS. However, the last year a clinician can receive a bonus under current law is 2024, based on the clinician’s participation in the Advanced APM in 2022. Most emergency physicians do not participate in Advanced APMs, and therefore must meet the MIPS requirements.
The 2023 performance year is the first year of a new reporting option in MIPS called the MIPS Value Pathways (MVPs). MVPs represent an approach that will allow clinicians to report on a uniform set of measures on a particular episode or condition to get MIPS credit. ACEP developed an emergency medicine-focused MVP that the Centers for Medicare & Medicaid Services (CMS) will include in the first MVPs batch starting in 2023. For more information about MVPs and the EM MVP, you can review this presentation highlighting the key aspects of MVPs and the final MVP policies.
While ACEP is excited about implementing this MVP, the Adopting Best Practices and Promoting Patient Safety within Emergency Medicine MVP, we understand that many emergency physicians may be skeptical about trying something new next year. Due to the COVID-19 public health emergency, hardship exemptions have been in place for the 2019, 2020, 2021, and 2022 MIPS performance periods. Therefore, for some clinicians, 2023 may be the first time they participate in MIPS in four years. These clinicians may not be willing to take a potential risk and try a different method for reporting in MIPS, especially when the potential downside is significant – a nine percent reduction in reimbursement on all Medicare-covered professional services.
ACEP recognized these potential and understandable reactions from emergency physicians and therefore recommended the following to CMS to encourage participation in MVPs:
- Create More Incentives for Participating in MVPs: ACEP believes there should be additional incentives for initially participating in an MVP over traditional MIPS. ACEP strongly recommends that CMS initially include at least a five-point bonus for participating in an MVP. Clinicians participating in MVPs should also be held harmless from any downside risk for at least the first two years of participation.
- Eliminate the Foundational Layer: MVPs include a “foundational layer” of population-based claims measures. ACEP believes that measures that should be included in MVPs are only those that specialty societies have developed to ensure they are meaningful to a physician’s particular practice and patients and measure things a physician can actually control.
Despite our recommendations, CMS declined in the final regulation implementing 2023 MIPS policies to modify the incentive structure for MVPs. However, ACEP was able to get clarification from CMS that clinicians can report both MVP and traditional MIPS measures, and CMS will take the higher of the two scores.
Now that the 2023 policies are finalized, we have boiled down the pros and cons of participating in MVPs to the following:
| Pros | Cons |
| Scored on 4 quality measures rather than 6, as in Traditional MIPS | Fewer options to choose from |
| Scored on fewer Improvement Activities than Traditional MIPS | It's new and there is no incentive to participate |
| CMS will take the higher of the MVP score and Traditional MIPS score | Similar scoring rules as Traditional MIPS (same performance threshold, performance category weights, etc.) |
| It is optional now, but may become mandatory going forward | It includes population-based measures that may not be attributable to emergency physicians |
Overall, given these pros and cons, we recommend that you consider reporting both MVP and traditional MIPS. Since CMS takes the highest of the two scores, the pros seem to outweigh the cons in terms of risk. However, you need to do what is best for your individual practice and keep in mind the time and cost associated with reporting additional measures.
To participate in the MVP, you will need to register for the MVP on the QPP website anytime between April 1 and November 30, 2023. ACEP will help you with the registration process as we get closer to that date. Registering for the MVP means that CMS expects you to try to meet the MVP reporting requirements, but you can still report other measures.
Beyond the introduction to MVPs, CMS continues to raise the bar in 2023 and future years. For example, CMS finalized a proposal to maintain the current data completeness threshold at 70 percent for the 2023 performance period but to increase the data completeness threshold to at least 75 percent for the 2024 and 2025 performance periods. The data completeness threshold is the minimum percentage of eligible patients that clinicians must report on for each quality measure. ACEP had opposed the proposed increase in the threshold for the 2024 and 2025 performance periods because it would increase the administrative burden and the overall cost of complying with MIPS requirements.
CMS will also keep the performance threshold (which clinicians need to achieve to avoid a penalty) at 75 points in 2023. This is the same threshold the agency established for 2022. ACEP supports CMS’s decision not to raise the threshold in 2023, as 75 points is already an extremely high bar to meet!
All in all, it may be more challenging than in previous years to avoid a penalty. The maximum negative payment adjustment in 2025 (based on performance in 2023) is -9 percent, and the positive payment adjustment can be up to 9 percent. Since MIPS is a budget-neutral program, the size of the positive payment adjustments is ultimately controlled by the amount of money available through the pool of negative payment adjustments. In other words, the 9 percent positive payment adjustment can be scaled up or down (capped at a factor of + 3 percent). In the first few years of the program, most clinicians qualified for a positive payment adjustment, so the adjustment size was relatively small. For example, if a clinician received a perfect score of 100 in 2020, the clinician only receives a positive adjustment of 2.3 percent in 2022 (much less than the 9 percent permissible under law). However, since the performance threshold is increasing so much in 2023, CMS expects that many more clinicians will receive a downward payment adjustment (a third of all clinicians!). Therefore, the maximum bonus for achieving a perfect score is projected to be 6.09 percent.
So, what can you do? One way to maximize your performance is participating in ACEP’s registry, the Clinical Emergency Data Registry (CEDR). CEDR will support the emergency medicine MVP in 2023 and can work with you and your practice to figure out the right reporting strategy and improve your performance. ACEP’s Regulatory and Quality teams can also help support you and answer any questions you may have.
Again, it’s time to start thinking about the best way to be successful in MIPS! And we hope this post and the following resources will help!
Author(s)
Jeffrey Davis
Director, Regulatory Affairs | ACEP
