MIPS For Physical Therapists, Occupational Therapists, And Speech-Language Pathologists: Friend Or Foe?

By Megan Henninger, PT, DPT, GCS, CEEAA

Director of Regulatory Affairs

Perception is reality. Medicare’s Quality Payment Program (QPP), in particular the Merit-Based Incentive Payment System (MIPS), is a prime example. You can quickly and understandably decide to view MIPS as a documentation nightmare or make this an opportunity to demonstrate your outcomes and value.

Some clinicians will say, “I became a clinician to treat patients, why should I care? This isn’t going to change how I treat. It’s just more paperwork.”  Others will mutter, “It’s just like Functional Limitation Reporting…it’ll be gone in a few years.”

We can’t think that way anymore in a MIPS world.

How we participate now is likely to influence how we get paid and how we practice in the future. So yes, it’s time to pay attention.

[WARNING: THIS IS A REGULATORY ARTICLE. WATCH OUT FOR HAZARDOUS ABBREVIATIONS!]

I’M A HEALTHCARE PROVIDER IN NEED OF THE BASICS. WHERE DID MIPS COME FROM?

MIPS started with a simple idea from Congress.

“Hey, Medicare,” they said. “Let’s take all of these programs that physicians have to participate in and put them into one so that we can try and simplify things.”

Sounds like a good idea, right? Sounds like common sense, right?

And so, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) brought us the QPP. The idea was to change reimbursement under the Physician Fee Schedule (PFS, translation: payment for outpatient services) from payment updates that are driven by regulation to payment updates that are driven by…quality.

Yes: Effective 2020, there will no longer be the potential for large payment updates mandated by Congress or Medicare. To receive Medicare payment updates, providers have two choices: participate in enough Alternative Payment Models (APMs) or participate in MIPS.

MIPS has been through many changes since its birth by legislation, but its core mission remains the same. For those who have difficulty finding a place in an APM world, providers are given a score based on how they perform in four different areas:

The four areas are weighted (and some are removed from the calculation based on the year and provider type) to create a composite score.

If a provider’s composite score is higher than the annual threshold score, they are eligible for an overall increase in payment from Medicare. If their score is lower, they may take a payment cut. Also up for grabs: extra money based on the medical complexity of patient-populations served and bonuses for performance that is considered exceptional.

WELL, THAT’S INTERESTING FOR PROVIDERS, BUT WHAT DOES MIPS MEAN FOR PHYSICAL THERAPISTS, OCCUPATIONAL THERAPISTS, AND SPEECH-LANGUAGE PATHOLOGISTS?

The answer: It depends.

MACRA has taken the simple math of the Physician Quality Reporting System (PQRS data+ claims = improved payment) and moved it into more complex algebra.

While physicians were eligible to receive the financial benefits of reporting through MIPS starting on January 1, 2017, PTs, OTs, and SLPs weren’t eligible until January 1, 2019. However, as the complexities of the program have grown, some practices found it beneficial to consider if they were eligible to report (which is a complicated three-part process) and weigh the risks of participating.

Given the complexities of the MIPS programs, registries such as the Physical Therapy Outcomes Registry (PTOR) and Focus on Therapeutic Outcomes (FOTO) have grown in their ability to meet this need. For many, moving to a Qualified Clinical Data Registry (QCDR – not an easy acronym to be awarded by the Centers for Medicare & Medicaid Services) has been the answer. QCDRs were designed to ensure optimal reporting while also providing the ability for providers to benchmark their performance against their peers.

Sounds exciting, right? Finally, I can look at my data and instantaneously compare it to the data of someone across the country. Finally, I can tell if I’m getting my patients better at the same rate as other providers. Sign me up!

HOLD UP. WAIT A MINUTE. I KEEP HEARING “PATIENTS OVER PAPERWORK.” MIPS SOUNDS LIKE MORE PAPERWORK?

You’re not wrong. MIPS is more paperwork for clinicians. The hope is that this will change in the future, but the system we have right now can be tedious.

But here’s what we have to remember: MACRA’s biggest focus was to permanently repeal the Sustainable Growth Rate (SGR) formula. [Don’t remember that? You’re far from alone. Reminder: This article is written by someone who lives in the weeds of regulatory policy. I’m here to help.] SGR was a budgetary formula that asked for a 20 percent cut to Medicare Part B by the time it was finally repealed. It required significant advocacy efforts on a regular basis to make sure Part B providers didn’t have to close their doors.

MIPS has to balance multiple priorities. It has to offer more money to “high quality” providers while providing potential penalties to those who are costing the system more money without delivering optimal care.

MAY I HAVE A METAPHOR FOR MEDICARE’S MOTIVATION BEHIND MIPS?

Yes: You notice every month you are spending more than you earn.  You consider not paying 20 percent of your bills for a second before realizing that while enticing, that’s not really possible. So you decide to re-evaluate how you spend your money.

Perhaps you invest in software that helps you track your spending. This leads you to discover you’ve have been spending too much money on soggy hoagies (or subs, sandwiches, whatever you call it [but it’s a hoagie]) from the convenience store around the corner for lunch every day. To remedy the problem, you determine it would be more cost-effective to buy really good deli meat at the grocery store and pack a lunch. This makes up the difference in your budget.

Medicare is, in essence, doing the same thing. The data coming from MIPS is how they are doing it. Rather than making big sweeping cuts based on a random decision, they are using the best information they can obtain to decide where to spend their money. This sounds logical.

Our friends at Medicare (yes, they are our friends) are doing the best they can to ensure they aren’t paying for soggy sandwiches.

BUT WHAT IF I AS A PT, OT, OR SLP BEG TO DIFFER WITH HOW MIPS MEASURES QUALITY?

You wouldn’t be the first to have a point of contention or two with a proposed regulation.

This is where you can do something.

The rules for this program and the measures available for review all have to go through a very stringent process. Every year Medicare has to tell the public how they plan to revise payment systems. They have to do this in every practice setting: hospitals, skilled nursing, home health, outpatient, all of them. To do this, Medicare proposes the rule for the next year. We (yes, we, everyday clinicians – isn’t it exciting!?!?) then have the ability to tell them what we think.

And the best news: They HAVE to read what we tell them.

This part is key: Medicare doesn’t have to do what we ask, but they at least have to consider our input.

The most recent proposal on the MIPS program is contained in the Physician Fee Schedule, which was released at the end of July. Yes, it’s long. To prevent some heartburn, the proposed updates to the QPP start on page 711. The MIPS measure sets for PT and OT are on page 1523. Those for SLP start on page 1567.

For those who enjoy getting sucked into the weeds, there is also some very interesting discussion of the physical therapy assistant and certified occupational therapy assistant coding changes, Current Procedural Terminology (CPT) codes for dry-needling, and some other fun nuggets if you want to comment on the whole proposal.

As providers, we are always encouraged to comment. Our professional associations do a wonderful job of protecting the practices of PT, OT, and SLP. But they can’t speak to the nitty-gritty details of how a policy will impact your specific practice because they don’t know them.

Only YOU know the policy that impacts your practice and only YOU can provide that information to Medicare.

This is our opportunity to provide more data to Medicare on how MIPS will impact us and, more importantly, the Medicare beneficiaries we see every day.

ALRIGHT, I’M READY TO COMMENT ON MIPS, BUT HOW EXACTLY DO I THAT?

First, don’t be afraid.

People make comments every day to Medicare, and some are … colorful.

Be articulate and be fair. Compliment the aspects of MIPS you like (accentuate the positive because, again with emphasis, these are our friends) and provide solutions to what you think might be problematic.

If you need help with a template, consider reaching out to your professional association. They may be able to provide overall recommendations and tips on areas that you can customize based on your practice. But remember, the key here is to customize.

Imagine this: Medicare gets 10 letters. They all have the same format: 12 pt Times New Roman, single-spaced, obvious signs of Find and Replace (If you’re going to do so, at least be mindful of misspelled words such as Dwigt), and run exactly 808 words. They are all advocating for a change but have only two examples of why the change should be made.

Does that make a strong case for changing a national program?

Conversely: They receive 20 letters. Each one has a different clinical reason as to why that one change should be made.

Does the argument become stronger? You betcha.

WHAT SHOULD I DO ABOUT MIPS MEASURES THAT DON’T TICKLE MY FANCY?

You can comment on why you think certain measures aren’t relevant to your practice, but the better answer is to get involved with the people who are making the measures. Getting involved in a QCDR is a great first step. These groups are looking at how to develop measures that appropriately measure current and future practice. Buyer beware: This process does take patience.

Proposing a measure takes time and it takes — you guessed it — data to support it. So help provide the data. If you’re not sure what you can do to help, someone at the American Physical Therapy Association, American Occupational Therapy Association, or American Speech-Language-Hearing Association might be able to help point you in the right direction.

The point here: Be involved in the best way you can.

I OPENED THE MIPS FILE. KNOW THAT INDIANA JONES SCENE WHEN THEY OPEN THE ARK?

First – deep breath.

If you don’t understand something, you’re not alone. Ask for help. Share it with a friend to see if they understand it. You might inspire them to get involved as well — even if they aren’t in health care!

Again, reach out to your professional association. The more informed advocates they have on their side the better. I also believe they would rather help you advocate for a change than help you deal with the downstream effects of a change, but this is conjecture. And maybe, you make a new friend like me on Twitter!

Another option: Talk to your electronic health record provider if you have one because we will someday be required to participate in the Promoting Interoperability (PI) category. We all want to report correctly. So, many of our EHRs have entire teams that are devoted to MIPS. There may be a webinar that you find helpful or a contact person who really helps to answer your questions.

SO IS MIPS MY FRIEND OR FOE?

Perception is reality. If you look at MIPS as an administrative burden with measures that don’t accurately portray our value, then it’s easy to call it your enemy. However, as you become more involved, you might find this is an opportunity for us to help shape health care moving forward. Perhaps ongoing conversation can make your foe into a friend.