Accountable Care Organization

Episode 53: Latest results in MIPS & MSSP

October 2023

The ACO’s Emily Levi reports MIPS and MSSP results for our participants and the financial implications.

Mike: This is BACON, brief news from the MaineHealth Accountable Care Organization. A monthly podcast for health care providers. I'm Mike Clark.

Heather: And I'm Heather Ward. Mike and I are practicing physicians who participate in the MaineHealth ACO.

Mike: In this episode, we explore the recently released performance results from MaineHealth ACO participants in the MIPS program and MSSP.

Heather: Sheesh, more acronyms. All right. Well, in just a moment, we'll get into exactly what MIPS and MSSP are and the implications these two Medicare programs have on the financial outlook for participants.

Mike: That's right. So, let's get to it.

Heather: All right. So, let's talk acronyms. We have MSSP and we have MIPS. Both are Medicare programs. MSSP, Medicare Shared Savings Program is what the ACO participates in, and MIPS, Merit-based Incentive Payment System is what providers participate in. So, Medicare just released performance information for ACOs that participate in MSSP and for all providers who are in MIPS. The MaineHealth ACO participates in MSSP, and most providers in the ACO are also in MIPS.

Mike: Yes, the annual performance scores that we get in MIPS and MSSP are kind of a big deal and have implications for how we all do financially. So, to give us the details, we've invited Emily Levi to join us this month. Emily is a program manager at the ACO who spends quite a bit of time researching the Medicare programs. Wow. Grateful for that. Welcome, Emily.

Emily: Hi, Mike. Hi, Heather. Thanks for having me.

Heather: All right. So, let's jump right into this. Let's talk about MIPS first. What exactly is MIPS and who participates in it? Is it everyone? Is it primary care only? Peds? General Surgery? Who's doing this work?

Emily: Yeah. So, MIPS, and I think you already covered the acronym, but I'll say it again because it's complicated is the Merit-based Incentive Payment System and providers that see Medicare patients. So any provider that sees Medicare patients, they have to see a certain amount of Medicare patients and bill at a certain amount of Medicare dollars each year. And if so, then they are required to report MIPS annually.

Heather: Okay, that helps. So if I had a very small Medicare population, I wouldn't necessarily be participating in MIPS?

Emily: That's right, Heather. A lot of our practices that are part of the ACO get what's called a small practice exemption, so they are not required to report MIPS if they are a small practice and there are several other exemptions as well, but that's the one that that is most often utilized by our participants.

Mike: So, is there an advantage to being in an ACO when it comes to MIPS?

Emily: Yeah, definitely. First of all, being in an ACO, we don't have to report for as many categories as what's called "traditional MIPS" supporters have to do so. There's four categories for MIPS: quality, cost, improvement activities, and promoting interoperability. So, the promoting interoperability category is essentially looking at EMR or EHR technology and how information is shared with patients through an EHR and how EHRs connect to each other. So, for those providers that are not participants in an ACO, they have to report the traditional MIPS "all categories." So, because we participate in MSSP, our providers get a full pass on the cost. We don't have to do anything for the cost category, and we get 100% points on the improvement activities category. So that right there is a huge benefit to the practices. And on top of that, we at the ACO, we really take in the details of the program so the providers don't have to. It's a really complex program and CMS changes the rules and adds a few details and changes things each year. So we really support the practices and understanding the requirements, especially for the promoting interoperability.

Heather: Okay, great. Emily, that's a lot of information. Can you break down the MIPS score for us?

Emily: Yeah, of course. So the MIPS score is made out of four different components, as I mentioned: quality, improvement activities, promoting interoperability and cost. And the ACO gets one overall aggregate score. So all of the participants get this score and participants have the option to report individually and take the higher of the two scores if they wish. And as I believe I mentioned, the ACO does not get scored on cost and we get full points on the improvement activities. So CMS takes our score for quality and promoting interoperability and that gives us one overall MIPS score. And then CMS looks at how we do compared to others across the nation, and that is how CMS determines what our corresponding payment adjustment will be.

Mike: Okay, so the MIPS score, which I admit is sometimes hard to fully understand, leads to a Medicare payment adjustment. So what was our MIPS score and what payment adjustment will we be looking at?

Emily: Our MIPS score for the 2022 performance year was 98.23 and that resulted in a payment adjustment that providers will see in 2024 and that payment adjustment is 7.17%. So the payment adjustment is always two years out and so MIPS eligible providers will see this payment adjustment on a claims by claims paid basis. So the paid amount on their fee for service Medicare claims for covered services.

Heather: That that seems like a lot like I don't remember it ever sounding like such a big percentage. Why is it so much larger this year?

Emily: It is, Heather. It is a lot higher. It's the highest payment adjustment that we have seen since participating in the program since back in 2017. So CMS has not yet released final data. But in talking with other ACOs and a national ACO association that we participate in, what we have gathered is that others most likely non ACOs did not perform as well. So, we're hearing that other ACOs like ours did perform really well. And so, because it's a budget neutral program, CMS has more money to give to a smaller pool of participants this year. So that's why our payment adjustment, we believe, is 4.8% higher than it was in prior years. CMS also has made some changes to the program in the past few years, so that's why we think some non- ACOs might have had trouble meeting some of the quality benchmark changes and some of the quality reporting changes that we ACOs do not yet have to comply with.

Heather: Ahh great. That's really helpful.

Mike: Okay, so we have some good news on MIPS score and at this point I'd like to shift to the MSSP program and take a look at our results under MSSP. Can you give us the highlights of our score for that program?

Emily: So there's two parts to our MSSP score: quality and cost. So we'll start with the quality score. Our final quality score was 86.47%, which is actually a bit lower, significantly lower than we performed in the prior year 2021. It was 100%. However, this is largely in part to CMS changing their scoring methodologies and less about how we did. We do have some areas where we can improve on, including the Patient Experience of Care survey and some other measures, but we improved in many areas and across the nation, there's a decline in the quality scores this year, with other ACOs having more like 70% for their scores. So we actually did significantly well in spite of CMS changing the rules this year.

Heather: Interesting. And so how about the cost? Did we save Medicare money this year in MSSP? And if we did, does that translate into shared savings?

Emily: So we did save CMS some money. Unfortunately, we did not save enough to get what is called an "earned payment", a shared savings payment. So, we saved the government $9.3 million, and we need to save $11.5 million to take home a payment. So that payment would have been split amongst our participants. But unfortunately, that didn't happen. But in the grand scheme of things, we were actually pretty close, just $60 per beneficiary, per year, short of getting a payment. And it does look like there are some opportunities to close those gaps and get that payment in future years. Unfortunately, it didn't happen this year. However, the good thing is that the way this program works is first CMS looks at cost and you need to meet that cost target first. And then if you meet the cost target, CMS looks at your quality score and you need to meet what CMS calls a quality gateway. So, as I said, our quality score was good and we did meet that quality gateway. So, if we had met that cost target, we would have taken home and earned payment this year.

Mike: So, we missed it by that much. All right. Yeah.

Emily: Yeah, I'd have heard some other ACO's missed it just by a few dollars per beneficiary per year. So that that would really stink.

Heather: That would be super frustrating.

Emily: Yeah.

Mike: Emily, this is a fabulous overview of the program. And you know, you've mentioned some changes that that affected our score and performance. Are there any major changes planned for these programs looking into the future?

Emily: Of course, CMS has to always keep us on our toes. So yes, there are actually some major changes that will occur in the quality component of this program. So as I mentioned, some other MIPS providers are already seeing some of those quality changes. So CMS is trying to align the MIPS and the MSSP quality reporting a bit more in the future. So there's measures are going to be aligned, but the major change is in how much we have to report and who has to report and how it happens. So right now, what happens is CMS gives us a sample of patients that we have to report on, and we look at where those patients are attributed. And the ACO manages that quality submission mainly by working with primary care providers. And what's going to change is that instead of the ACO provider, what's going to change is that instead of the ACO manually going in to the EHRs and pulling the quality data, the data is going to have to be pulled electronically from the electronic health record, meaning our participants have to make sure they are meeting EHR requirements that EHR are up to date and they have to also be making sure that they're documenting in a certain way so that data can be pulled directly from the EHR. It means less opportunity, for example, to go in and pull information from notes sections in the EHR.

Emily: Information is going to have to be documented in what's called a discrete field. And so, this is very complex and it's also a lot more reporting. CMS is also looking at all providers having to report across all payers. There's some different options for reporting that we may not have to do that, but we're still exploring that. However, because this is so complicated, we're planning on working with a vendor to help support us. So, we're finalizing that contract right now. The change goes into effect for program year 2025. So we're hoping that we have one year to do an optional submission and sort of work out the kinks of this program and look at where we have opportunities to improve our quality scores before we have to report for the 2025 program year. So the ACO will still be working closely with the practices and really making sure that they know what they need to do for this. And over the next year you'll be hearing if you're a practice participating with the ACO, you'll be hearing a lot more from us and you'll be, we'll be working with you closely to be ready for this change. It is a pretty major change, so we're excited to have a vendor on board, hopefully soon to help support us with this transition.

Heather: Great. Yeah. Sounds like a lot of work coming here in the very near future to be prepared for 2025. Thank you so much for your time, Emily. We really appreciate it. It was great to get some insights into these two programs. You know, we hear about them a lot or might hear people refer to them, but getting this kind of insight in detail is really helpful.

Emily: Yeah, of course. It's a really complicated program and I'm happy to be able to support the practices in understanding what they need to do. And if anyone else is interested in learning more, has questions, don't hesitate to reach out to me.

Heather: Great. Thank you so much.

Mike: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page, And if you have questions, comments or suggestions, we'd love to hear from you. Please email us at That's

Heather: Bacon is produced by the MaineHealth Accountable Care Organization. Thanks for joining us. See you next time.

Mike: See you next time.