Cost

Measuring cost is an important part of MIPS because cost measures show:
• The resources clinicians use to care for patients.
• The Medicare payments (for example, payments under the Physician Fee Schedule,
IPPS, etc.) for care (items and services) given to a beneficiary during an episode of care.
An episode of care is the basis for finding items and services from claims given in a
specified timeframe.

What are Cost Measures?
For 2018, MIPS uses cost measures that cover the total cost of care during the year or during a hospital stay. We plan to use episode-based measures in the future.
The Cost performance category uses your Medicare claims data to collect Medicare payment information for the care you gave to beneficiaries during a specific period of time. Because we use Medicare claims data, we’ll calculate the Cost performance category score and you don’thave to submit any data.

For the 2017 transition year, the Cost performance category didn’t count toward your total MIPS score. In year 2, it does count for 10% of your total MIPS score.

Transition year (2017)

We used a 0% weight for the Cost
performance category when we calculated
your MIPS final score for the transition year
(2017 MIPS performance period).
The cost category was given a 0% weight in
the 2017 calculations to give you the chance
to understand the attribution and scoring
methods.

Year 2 (2018)

We finalized a weight of 10% for the 2018
MIPS performance period to help you get
ready for a higher weighting in the future.
The 10% cost weight will help you:
• Have an easier transition to the 30%
cost weight MACRA requires starting
with the 2019 MIPS performance
period.
• Urge you to review and understand
your performance on cost measures.
If you participate in a MIPS APM, the MIPS APM will apply a 0% weight to the Cost
performance category because many MIPS APMs measure cost in other ways.

How are Cost Measures Calculated?
Our goal is for cost measures to go with the quality of care assessment so that we can work toward better patient outcomes and smarter spending at the same time. Events such as hospitalizations, readmissions, and certain complications can be identified through claims analysis and can inform on the quality of care furnished during an episode. Because these events can be captured using claims analysis, no additional data submission is required. Cost measures are risk adjusted to account for differences in beneficiary-level risk factors that can affect quality outcomes or medical costs, regardless of the care provided. The goal of risk adjustment is to enable more accurate comparisons across Medicare Taxpayer Identification Number (TINs) that treat beneficiaries of varying clinical complexity, by removing differences in
health and other risk factors that impact measured outcomes but are not under the TIN’s
control.

What are the Year 2 Cost Measures?
In year 2, we will only use two cost measures to measure performance:
• Total Per Capita Cost measure
• Medicare Spending Per Beneficiary measure
Total Per Capita Cost (TPCC) Measure
The TPCC measure measures of all Medicare Part A and Part B costs during the MIPS
performance period.For the TPCC measure, beneficiaries are assigned to a single Medicare Taxpayer Identification Number/National Provider Identifier (TIN-NPI) in a two-step process that considers:

• The level of primary care services they received (as measured by Medicare allowed
charges during the performance period).
• The clinician specialties that performed these services.
Only beneficiaries who received a primary care service during the performance period are assigned to the TIN-NPI. Here are the two-steps used to assign beneficiaries to a TIN-NPI for the TPCC measure:
1. If a beneficiary received more primary care services (PCS) from primary care physicians (PCPs), nurse practitioners (NPs), physician assistants (PAs), and clinical nurse
specialists (CNSs) in that TIN-NPI than in any other TIN-NPI or CMS Certification Number
(CCN), the beneficiary is assigned to the TIN-NPI in the first step.
• If the beneficiary received more PCS from PCPs, NPs,
PAs and CNSs from a CCN than any other TIN-NPI, this
beneficiary:
o Would be assigned to the CCN.
o Wouldn’t be assigned to any TIN-NPIs.
o Would be excluded from risk adjustment.
If two TIN-NPIs tie for the largest share of a beneficiary’s primary care services, the beneficiary will be assigned to the TIN-NPI that last gave primary care services.
2. If the beneficiary did not receive primary care service from any PCP, NP, PA, or CNS
during the performance period and received more primary care services from non-primary care physicians within the TIN-NPI than in any other TIN-NPI or CCN, the beneficiary is assigned to a TIN-NPI in the second step.
Please note that if two TIN-NPIs tie for the largest share of a beneficiary’s primary care
services, the beneficiary will be attributed to the non-primary care TIN-NPI that provided primary care services most recently. If the beneficiary received more PCS from non-primary care physicians from a CCN than any TIN-NPI, this beneficiary would be attributed to the CCN, would not be attributed to any TIN-NPIs, and would be excluded from risk adjustment. If the beneficiary did not receive any primary care service via PCP, NP, PA, CNS or non-primary care physician, then the beneficiary wouldn’t be attributed.
Medicare Spending Per Beneficiary (MSPB) Measure:
The MSPB clinician measure determines what Medicare pays for services performed by an individual clinician during an MSPB episode: the period immediately before, during, and after a patient’s hospital stay.
An MSPB episode includes all Medicare Part A and Part B claims during the episode,
specifically claims with a start date between three days before a hospital admission (the “index admission” for the episode) through 30 days after hospital discharge.
The MSPB measure is assigned to individual clinicians, as identified by their unique TIN-NPI. MSPB measure performance may be reported at either the clinician (TIN-NPI) or the clinician group (TIN) level.

How Will I Get Performance Feedback?
You may have already been getting feedback for several years on cost measures from the
Value Modifier program reports and the Physician Feedback Program, Quality and Resource
Use Reports (QRURs). In 2018, we’ll give you feedback on cost measures used in the 2017
MIPS transition year. Although the Cost performance category doesn’t affect your payments for the transition year, we’ll still give you performance feedback to help you get familiar with cost measures.

How Will I Be Scored?

We’ll calculate your or your group’s Cost performance if the case minimum of attributed
beneficiaries (i.e., 20 cases for total per capita cost measure, or 35 cases for MSPB measure) is met. If the case minimums aren’t met for either of the 2 measures, we’ll reweight the Cost performance category weight to the Quality performance category. This will make the Quality performance category worth 60% of your 2018 MIPS total score.
To figure your Cost performance category score, we’ll
• Assign 1 to 10 points to each measure.
• Compare your performance to other MIPS-eligible clinicians’ and groups’ during the
performance period, not on a past year.
The Cost performance category score is the average of the 2 measures, but If only 1 measure can be scored, that score will be the performance category score.

How are episode-based Cost Measures Built?

There are 5 key parts to building episode-based Cost measures:
1. Defining an episode group
2. Assigning costs to the episode group
3. Attributing the episode group to one or more responsible clinicians
4. Risk adjusting episode group resources or defining episodes to compare beneficiaries that are alike
5. Aligning as much as possible, episode groups with quality indicators