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Answered: FHIR in the 2023 Final Rule, Small Practices in an MSSP ACO + more!

In this episode, Dr. Dan Mingle answers follow-up questions from the 2023 Final Rule. Featuring insight into FHIR in 2023, an overview of Hospitalist Measures in the coming Performance Year, Small Practice PI Exceptions, and much more.

Click play to listen to this episode now, or scroll down to read the summary of each question and answer below.

Question One: Small Practice PI Hardships in 2023

Lisa asks: “On Promoting Interoperability, will Small Practices automatically get a PI Hardship for 2023?”


Small practices no longer need to ask for a PI hardship exception. It is granted automatically and redistributes the points entirely to the Quality category.

So instead of 30%, Quality will be 55% of your total score.

But PI will be scored if you’re a Small Practice and still choose to submit for the category.

Question Two: Adult Immunization Status Measure

Lisa also asks: “On the Adult Immunization Status measure, do you know if flu and pneumonia will have individual numbers? Or will the score will a combination of both?”

The score will be a combination.

The Adult Immunization Status, Measure #493, is new to the MIPS Measure menu for 2023.

This measure is only available as a MIPS CQM and applies to patients 19 and over.

The measure is looking for patients whose vaccinations are up-to-date for:

  • Influenza
  • Tetanus – Td or Tdap
  • Zoster
  • Pneumococcal

The measure is reported with a different numerator for each of the immunizations listed above, and is scored on the weighted average of all four.

Question Three: FHIR in the 2023 Final Rule

Lolita asks: “Was FHIR referenced in the 2023 Final Rule?”

FHIR was mentioned in the 2023 Final Rule:

  1. As a request for Information on Continuing to Advance to Digital Quality Measurement and the Use of Fast Healthcare Interoperability Resources (FHIR) in Physician Quality Programs.
  2. FHIR was also mentioned as a request for Information on Advancing the Trusted Exchange Framework and Common Agreement (TEFCA).
    • TEFCA is a framework for the bi-directional exchange of health data.

There are no new standards or requirements for FHIR – it remains one of the methods for exchanging data. Anyone looking ahead to a future single standard method probably thinks about FHIR as the most likely option. But we don’t know when or if it will be a requirement.

And on that note, data standards requirements are an interesting double-edged sword:

  • Setting a requirement can dramatically accelerate adoption, but setting a requirement can be a detriment if the goal is for quality reporting to reflect the quality of care (rather than the quality of data infrastructure).

Question Four: SDOH Screenings

Lindsey asks: “Are Social Drivers of Health screenings only going to be required for the acute inpatient setting, or will ambulatory settings also be required to screen for SDOH?”

This question pertains to Measure #487, Screening for Social Drivers of Health, a new measure available in the MIPS menu for 2023.

This measure is only available as a MIPS CQM. It is not available as an eCQM, Claims measure, or Web Interface measure.

This measure is included in most specialty measure sets, but it is not available in these specialties:

  • Anesthesiology
  • Dentistry
  • Electrophysiology
  • Hospitalists
  • Pathology
  • Radiation Oncology
  • Speech and Language Pathology

This measure is not a requirement – it’s just one of your options.

Question Five: Traditional Medicare vs. Medicare Advantage Plans

Mel asks: “How do the yearly changes keep CMS value-based programs competitive with Medicare Advantage plans?”

Fascinating question, Mel!

Finding reliable data comparing traditional Medicare to Medicare Advantage plans is challenging.

For some background: Medicare Advantage was established in 1997, and enrollment has steadily increased, hitting 48% in 2022. The Congressional Budget Office predicts 61% enrollment by 2032.

According to The Kaiser Family Foundation, Medicare Advantage plans have never generated savings relative to traditional Medicare.

And this is sort of an apples-to-oranges comparison:

  • Medicare Advantage caps out-of-pocket expenses.
  • Medicare Advantage plans win bids by bidding below the benchmarks of predicted Medicare Parts A and B services.
    • But they can earn more from Medicare with rebates for extra benefits.
  • Medicare Advantage plans can shape their enrollee profile through selective marketing.
  • And Medicare Advantage plans can shape their cost profiles through network selection.
    • Some data suggests Medicare Advantage enrollees receive care from sources with lower quality ratings than traditional Medicare recipients.
  • Medicare Advantage has been training longer on risk coding compared to traditional Medicare.
  • And in 2019, Medicare Advantage cost Medicare $321/beneficiary more than traditional Medicare:
    • $11,844 vs. $11,513

Concerning your question, Mel, I conclude that traditional Medicare is competitive with Medicare Advantage. And value-based care dynamics are likely to accentuate the dynamics that favor traditional Medicare by encouraging:

  • Cost containment.
  • Attention to performance standards.
  • And attention to risk-relevant coding that makes the populations more comparable.

Question Six: Historic MIPS Scores and MSSP Membership

Trish asks: “Can you comment on the role of historic MIPS scores when evaluating new practices for MSSP membership?”

Historic MIPS scores are absolutely something you should consider as you build your ACO.

Strategically, your path is clear: You want to be at or above the quality threshold to collect your full allotted share of savings.

Tactically, what you do with any particular practice depends on the circumstances related to your ACO and the practice proposed for membership.

Your ACO will be in one of two circumstances: you could be comfortably at or above the quality threshold or struggling to either get there or stay there.

If you are struggling, bringing in a practice that will pull your scores down could be an expensive mistake. It could be the deciding factor that means you won’t share in your generated savings.

If you are comfortably above the quality threshold, you may be able to count on the average score across your participants to keep you in the full sharing range.

I’d ask for the proposed new practice to share their recent MIPS feedback reports to understand what they have been scoring historically.

If they did not submit any of the three measures of the APP, you should ask for credible data to establish historical expectations. There might be a canned report or a different quality program they participated in, which could predict where they will land.

It would be best if you understood how they were measured historically. Succeeding on a sampling of patients by manual chart audit is different from measuring at least 70% of all eligible patients of all insurers.

Better yet, you could do a trial run of their data with your reporting vendor to see where their scores land and will land your ACO using the applicable specifications. An added advantage of this latter approach is that you can verify that their data is accessible and readable.

Finally, be sure to include your experience of your success in supporting your member practices to elevate their scores in your analysis of future potential members.

Question Seven: Incentives for MIPS

Shephali asks: “Since the Exceptional Performance Bonus has ended, what incentives are there for providers who score 95 or greater?”

In any year of MIPS, Medicare has not yet genuinely graded on a statistical curve in which you’d expect 50% to suffer a negative adjustment and 50% to enjoy a positive adjustment.

If it were truly balanced, you’d expect peak losses to be 9% and peak gains to be 9%.

With tiny numbers suffering negative adjustments, positive adjustments have been driven mainly by the Exceptional Performance Bonus.

  • That exceptional performance bonus has driven peak positive adjustments to 1.8%.

We lost that foundational 1.8% positive adjustment with the lapse of the Exceptional Performance Bonus.

Offsetting that somewhat is the legislative requirement that the Performance Threshold is set at the average:

  • At the discretion of the secretary of health and human services, the average can be either the mean or the median.
  • And it can be the mean or median of any prior year. So, scoring is still not truly on a statistical curve.

With the phase-in and COVID dynamics, we’ve not experienced a “normal” year of MIPS yet.

Medicare has floated their prediction for 2023 to be a 3% or better maximum positive adjustment. My guess is it will come in lower than that, and we will see something between 1% and 3%.

Question Eight: Small Practices in an MSSP ACO

Sharon asks: “Will our MSSP ACO with multiple TINS be eligible for the Small Practice exception based on the TINs participating in the MSSP? Meaning, multiple TINs are Small Practices that roll up into our basic track MSSP program – will each designated Small Practice receive the automatic exception for Promoting Interoperability?”

The answer is an equivocal “yes” and “no”.

There are two applicable requirements for Health IT in your Basic Track MSSP program that is not an Advanced APM:

  • One of those requirements is MIPS.
    • All MIPS-eligible providers in an MSSP ACO (that is not an Advanced APM) have a MIPS requirement for Promoting Interoperability.
    • This MIPS requirement is subject to all the standard terms of any MIPS submission, including the automatic exception for small practices.
  • But there is also an MSSP contracting requirement that 75% of participants be on CEHRT.
    • That contractual agreement is based on the attestation represented by the contract and is subject to verification through an audit.

Question Nine: Hospitalist Measures in 2023

Liz asks: “What will the Hospitalist measures look like going into 2023?”

CMS removed one measure from the Hospitalists Specialty Measures set in the 2023 Final Rule:

  • Measure #76: Prevention of CVC Related Infections

And these measures will still be available:

  • Measure #5: ACE or ARB in LVSD
  • Measure #8: Beta Blocker in LVSD
  • Measure #47: Advance Care Plan
  • Measure #130: Documentation of Current Medications

Below, I’ll outline a few items to consider as you decide what to submit for MIPS in 2023.

Consider a Facility-based submission:

  • A Hospitalist practice might qualify for facility-based participation.
  • Remember that a provider is not an NPI but a TIN-NPI.
  • In Medicare’s eyes, a provider is a distinct entity in each of the TINs in which they bill.
  • If 75% of a provider’s billings come from a hospital location, the provider can claim the facility’s quality score.
    • Or the whole practice can claim the facility quality score.

Additionally, you can use any MIPS measure if you perform the quality action. You are not restricted to your specialty set.

If you’re a Mingle Health customer, our analysis of your claims can give you a complete list of the measures for which you have case minimums.

And remember that a significant advantage of the specialty set is that the four measures in the set are considered a complete submission. You don’t have to scramble to find two more measures that don’t fit well to complete your MIPS submission.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, Primary Care First, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

Understanding the Cost Category

As most MIPS participants know, the Cost Category is complex and full of variables. This complexity can make eligibility, scoring, and measure types tough to understand. If you'd like to increase your understanding of the Cost Category, access our latest video presentation in the Mingle Health Resource Center.

Access the Video
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