MACRA 101: MIPS and the Resource Use Category

Bherti Patel
Associate Editor
Loyola University Chicago School of Law, JD 2018


As previously discussed, MIPS will streamline Medicare’s current quality measures into one composite score from four reporting categories: Quality, Resource Use, Advancing Care Information, and Clinical Practice Improvement. This score will then be used to determine the reimbursement to a clinician based on his or her performance. In this article, we will discuss the Resource Use category.

The Resource Use category is the utilization component of MIPS and will replace the current Value Modifier Program (“VM”). One major change in the Final Rule is that providers will not be evaluated on Resource Use until performance year 2018. However, CMS will provide feedback on clinicians Resource Use performance in 2017 even though that data will not have an impact on their reimbursement. As performance feedback becomes available from claim analysis, the Resource Use category’s contribution to the overall performance score will increase to the statutory 30% level by 2021. The score will be based off of an average of all relevant resource measures. Like the current Value-Based Payment, CMS will use Medicare administrative claims data to calculate the Resource Use score. Clinicians will not be required to report separately from their Medicare claims data, however, beginning in 2018, clinicians will be required to include additional codes on the claims themselves.

The VM is one of the programs CMS modeled their Resource Use category off of. It is made up of two components—quality and cost. The MIPS Resource Use category will replace the cost component of the VM program. For the cost component, VM singularly looks at hospitalization costs and scores six measures of “resource use.” One of these six measures is episode-based, while the other five measures are the total per capita cost. For the episode-based measure, the VM scores the Medicare Spending per Beneficiary (“MSPB”). MSPB looks at the combined amount incurred by the patient beginning three days before admission and ending at 30 days after discharge.

MIPS is keeping the total per capita cost measure and MSPB for Resource Use but is lowering the attribution threshold to 20 beneficiaries from the current 125 for scoring. CMS will also be using 40+ episode-specific measures (such as chronic heart failure or atrial fibrillation) to take into account the differences amongst specialists for the remaining four measures to report. Each measure may earn up to 10 points, based on a percentile benchmark scale which takes into account the number of cases, performance score, and the measure’s performance threshold. The overall Resource Use score will be calculated by adding each scored measure and dividing by total possible points available (10 per measure). Each episode measure has a threshold that a clinician must reach in order for that measure to be calculated in the Resource Use score. If a clinician does not reach the specific number, typically 20 cases, the measure will not be scored and, therefore, makes the remaining scored measures count for a great percentage of the clinician’s overall Resource Use score.

For episode based measures, beneficiaries will be attributed to the provider who bills a Medicare claim during the initial treatment that begins the episode, the “trigger event.” CMS recognizes that more than one eligible clinician may be attributed to a single episode of care, specifically in the case of acute condition episodes. They have addressed this issue by proposing that acute condition episodes would be attributed to all clinicians who bill at least 30% of the Evaluation and Management visits during the trigger event. For procedural episodes, all eligible clinicians who bill a trigger code during the trigger event will have the episode attributed to them. The definition of a triggering event will vary depending on whether it is an impatient or outpatient procedure.

Prior to implementation, CMS will develop classification codes that correspond to categories of care episodes, patient conditions, and patient relationships (to attribute patients to more than one physician). Beginning on January 1, 2018, clinicians will be required to include these codes on Medicare claims. This data will be used to compare utilization for similar patients, care episodes, and conditions for specified time periods.


What Now?

 MACRA represents a general change in the way clinicians are compensated to provide care to Medicare patients. This change is being implemented in order to ensure that patients receive the best care possible and that clinicians are being paid according to the quality of services they provide. Despite its relatively low impact in the first few years, organizations and clinicians may want to consider how the Resource Use category could potentially impact their care model. The Final Rule provides clinicians with the ability to receive feedback before actually having their Resource Use score impact reimbursement and this opportunity should be taken advantage of. An evaluation of how certain episodes are coded as well as what triggers each event may lead to discovering new ways to maximize scores under the Resource Use category.  Compliance officers should consider how they can disseminate the idea that coding may need to be altered in order to maximize this score and identify who the key players are to help implement changes and maximize reimbursement.  The Resource Use category will not have a great impact on clinicians’ MIPS scores until a few years after implementation, but this intricate component of the already complex rule is imperative and should be thoroughly understood by clinicians affected by MIPS. It is important for organizations to understand, plan, and prepare for the changes that this new program will bring about.