[PART 2] Understanding MIPS 2018: Cost and Quality

Welcome to part two of our four-part series on the MIPS 2018 program. In last week’s post, we covered the basics of the Quality Payment Program. We reviewed where it came from and the major components of the program. We dove a little deeper by reviewing who is eligible for the MIPS program, how the scoring works and your options for reporting. If you missed any of that you can catch up by reading [PART 1] Understanding MIPS 2018.

This week, we begin with a look into the Cost and Quality categories of the MIPS program. This post will help you understand what is required for each of these categories and also offer tips for succeeding with your 2018 reporting. 

Let’s begin with the Cost category.


The Cost category is not necessarily new, but it is newly included in your total MIPS score this year. The Cost category used to be known as the Physician Value-Based Modifier program. The cost measures will likely look familiar to you if you have been monitoring your QRUR reports from CMS.

As we discussed last week, your total MIPS score is determined by your performance in four different categories, which are Quality, Cost, Improvement Activities and Advancing Care Information. The Cost category makes up 10% of your final MIPS score.


CMS will only evaluate two measures in the Cost category for 2018: the Medicare Spending per Beneficiary (MSPB) and the Total Per Capita Costs for All Attributed Beneficiaries (TPCC) measures.

The Medicare Spending Per Beneficiary (MSPB) clinician measure assesses the cost to Medicare of services performed by an individual clinician during an MSPB episode. The Total Per Capita Costs for All Attributed Beneficiaries (TPCC) measure is a payment-standardized, annualized, risk-adjusted, and specialty-adjusted measure that evaluates the overall cost of care provided to beneficiaries attributed to clinicians.

CMS will calculate Cost measure performance based upon the administrative claims you submit; therefore, no action is required from clinicians. CMS will use all 365 days’ worth of 2018 data to make this evaluation.

In 2017, they used similar data to evaluate your performance even though it wasn’t included in your total MIPS score for 2017 reporting. Those reports are available now for you to review.


CMS will calculate the Cost performance at either an individual or group level using administrative claims data. The total score is calculated by averaging the score of the two measures together. 

To calculate the score for each measure the individual or group must meet the case minimum. For the MSPB measure the case minimum for reporting is 35 episodes and the TPCC measure has a case minimum of 20 episodes.

If you do not have enough cases to meet the case minimum, the score will be based on the performance of one measure for which you have enough cases. 

CMS will compare your performance with other MIPS Eligible Clinicians and groups during the 2018 performance period. This means benchmarks are not created from a previous year’s data. These benchmarks, once created, will be used to assess your performance for 2018. CMS will determine who gets the full 10% credit for this category versus 9% or 8% etc.


CMS has already released your 2017 Cost performance. I suggest that you go to your QRUR reports now and see how you did on these two measures. This will help you gauge how well or poorly you performed. It’s not too late to create a plan to better your performance over the course of 2018 reporting year.

Congress recently passed new tax law (The Bipartisan Budget Act of 2018). In this bill they made some changes to MIPS. The MIPS transition years were supposed to be 2017 and 2018. This new law extended the transition year all the way to 2021. The Cost category was supposed to go up to 30% weight of your total MIPS score by 2019, but with the new bill, that’s pushed back all the way to 2022. No one is sure yet how quickly the Cost category weight will rise. Keep in mind that CMS may include more episode-based measures in following years.

Finally, you may remember hearing something about a Cost improvement bonus. That has been eliminated for 2018 and the transition years to follow.


This is the second year that the Quality category will be counted toward your total MIPS score. Last year, it was worth 60% of your total MIPS score. This year, with the addition of the Cost category, it is now worth 50% of your total MIPS score.

Remember that the Quality category replaces the old Physician Quality Reporting System (PQRS) program. It went through a few changes, but it’s pretty similar, but keep in mind that in the Quality category – and all of the MIPS categories – the level of your performance is what really matters to CMS. So, it’s important that you realize this isn’t just about submitting some random numbers and checking it off your list. This program is supposed to be about transforming your Quality programs to provide better quality of care at a better cost.


6.png You must report a total of six Quality measures to CMS. 

You must submit at least one Outcome measure unless there is not one available in your specialty measure set. If so, you can report a High Priority measure in its place. 

15.png If you are reporting via the CMS Web Interface method, you need to report all 15 Quality measures.

Reporting Methods

The number of measures available for you to choose from depends upon the method of reporting you plan to use to submit your Quality measures to CMS.

The methods include:

  • Claims – 73 available measures (This option is for individual reporting only.)
  • Registry – 265 available measures (Must choose six measures or measure set.)
  • CEHRT – 54 available measures (Must choose six measures.)
  • CMS Web Interface – 15 available measures (This option is only available for groups with 25 or more Eligible Clinicians. Report all 15 Quality measures.)
  • QCDR – Depends on the measures the QCDR created. (Must still choose six measures or measure set.)

Note: If you are submitting using the CMS Web Interface reporting option you must let CMS know by June 30, 2018.

Performance Benchmarks

As you are accustomed to, you will report numerators, denominators, exceptions and exclusions for each measure giving you a performance rate. CMS published the 2018 Quality measure benchmarks for each measure and those benchmarks reflect performance according to the method of reporting you use. These numbers are important because your performance determines which benchmark you fall into which determines how many decile points you receive in this category and ultimately how you perform overall. 

The benchmarks are divided into deciles:


For any measures that fall into the Decile 3 to Decile 10 range you can earn from three to 10 points for each of the measures that you submit. Depending on which decile you fall into, you’ll receive a different score.

60.png Your goal is to improve your quality score  by improving your measure performance each year, reaching for the high of 60 points (six measures worth up to 10 points each).

Below is a chart showing you how many points you’ll receive based upon the decile your where your measure performance ranks.


Number of Points Assigned for the
2018 MIPS Performance Period

Below Decile 3 3 points
Decile 3 3-3.9 points
Decile 4 4-4.9 points
Decile 5 5-5.9 points
Decile 6 6-6.9 points
Decile 7 7-7.9 points
Decile 8 8-8.9 points
Decile 9 9-9.9 points
Decile 10 10 points

The level of performance varies for each measure in each decile, so you need to monitor your performance in relation to the deciles in order to have a sense of how well you are doing.

Each measure must also meet the Case Minimum requirement of 20 cases for 2018.

Another consideration is the Data Completeness requirement. For all measures submitted, you must include at least 60% of all patients eligible for the measure across all payers. This is up from the 50% data completeness requirement of 2017.

If the measure you submit does not meet the Data Completeness requirement, then regardless of your performance score, you will only receive one point for each measure. The only exception to this requirement is for small practices who will still receive at least three points even if the case minimum requirement is not met.

Note: To see the decile range and point association for all measures visit the CMS website 2018 resources page and scroll down to the link “Quality Benchmarks.”


60.png The number of points that you can earn for reporting six quality measures is 60 points (six measures worth up to 10 points each). Your category score can be maximized through quality improvement, smart measure selection, submitting your best measures and choosing measures that are High Priority or an additional Outcome measure.
15.png If your group includes 15 or more clinicians, CMS will calculate the All Cause Readmission measure based on administrative claims data only if there are 200 or more attributed hospitalizations.

If this measure is calculated, an extra 10 points will be added to your Quality point denominator (70) and your level of performance on this measure will be determined by CMS.

If your performance is the best possible for all six measures, you will earn 60 points, but should you fall short, CMS has built in the opportunity for you to earn some bonus points.


6.png There is a possibility to earn one bonus point for each measure reported electronically to CMS, for a total of six bonus points for reporting by CEHRT or through a reporting vendor, like Medisolv. This reporting must be end-to-end electronic reporting with no human handling of data between the EHR and CMS.
6.png There is also a possibility to earn an additional six bonus points by choosing extra Outcome or High Priority measures beyond the one required Outcome measure. Of your six measures that are reported, an extra Outcome or Patient Satisfaction measure would earn two bonus points. For each measure that qualifies as a High Priority measure, one bonus point is available. The maximum extra High Priority measure points available is six points.
6.png You can receive up to 10 percentage bonus points added to your Quality score if you improve your measure performance over last year. Keep in mind that in order to be eligible for  this bonus, you must submit at least one or more measures in 2018 that you also submitted in 2017 and there must be sufficient data to measure improvement.

CMS will compare your improvement with the reported improvement by your peers.The amount of improvement that will earn the 10% bonus will be determined only after 2018 reporting is complete and CMS has compiled the improvement achieved across the quality measures reported by your peers.

The Quality Payment Program website is a terrific resource to look up your measures by method of reporting and to determine if each measure is considered an Outcome or High Priority measure.


Report six and only six Quality measures. If you submit more than the six measures (excluding the CMS Web Interface option) CMS will choose which Quality measures they count toward your overall performance. When you choose your Quality measures ensure they are the ones that reflect your best performance.

Be sure include at least one Outcome measure. Avoid measures with no benchmark or measures that are topped out. 

Look for bonus point measures.

Report measures that meet the case minimum and data completeness requirements. 

Choose your quality reporting vendor and understand how they will support you in the calculation of your possible MIPS points on Quality, as well as helping you to meet all of the MIPS program requirements.

If you would like to learn more about the Medisolv MIPS solution, please contact us today.



What’s in store for MIPS year three?

In this free educational webinar, we discuss who is eligible for the MIPS program in 2019 and what’s required for successful completion of the program. We also outline strategies that will help your providers gear up for their best reporting year yet.

Here’s what’s covered in this webinar:

  1. Changes made in the 2019 final rule for the Quality Payment Program
  2. Reporting requirements for MIPS
  3. How the final score is calculated
  4. Best practices for preparing your clinicians for a successful quality reporting year

Download Webinar Now

Erin Heilman