MIPS: Navigating The Cost Category

Matthew Klein
Quality Programs Specialist

This week, we’re wrapping up our latest blog series, MIPS: A Closer Look, by diving into the last MIPS reporting category, Cost. In case you missed it, this series has been a part of TSI Healthcare’s ongoing commitment to helping you stay informed about the Merit-based Incentive Payment System.

Catch up on all of the blogs in our series now!

  1. MIPS: Navigating The Advancing Care Information Category
  2. MIPS: Navigating The Improvement Activities Category
  3. MIPS: Navigating The Quality Category
The Cost category, formerly known as the Value-Based Payment Modifier, is a unique reporting category in 2017 because it will account for 0% of your overall MIPS composite score. However, in 2018 this category’s weight will jump to 10% of your overall MIPS composite score. This shift in scoring weight is due to the number of changes that will take place with this new reporting program and the new category requirements for MIPS. The focus for the Cost category is to reduce unnecessary spending such as readmission to hospitals and additional testing by focusing on preventative and outcomes based care.


Scoring for this category will be a comparison against peers based on resources used to treat similar care episodes and clinical condition groups.  Cost measures for 2018 will derive from cost measures used in early program years. These measures include:

  • Total per Capita Cost per Beneficiary
    • A payment-standardized, annualized risk-adjusted, and specialty-adjusted measure that evaluates the overall efficiency of care provided to beneficiaries attributed to solo practitioners and groups using ALL Medicare Part A and Part B claims.
      • This includes visits to other providers, visits to hospitals, and inpatient stays.
      • This will be included as a part of the cost category in 2018.
    • Total per Capita Cost by Four Chronic Conditions
      • Calculated similarly to total per capita cost per beneficiary, but concentrates on COPD, CAD, diabetes, and health failure.
        • This will be included as a part of the cost category in 2018 but will be expanded to include more disease types and episodes of care.
      • Medicare Spending per Beneficiary (MSPB)
        • MSPB assesses the cost to Medicare of services performed by TINs during an MSPB episode. This comprises the period immediately prior to, during, and following a patient’s hospital stay (3 days prior to and 30 days post admission).
          • This only includes inpatient stays.
          • This will be included as a part of the cost category in 2018.

Cost episodes will be developed based on different episodes of care that fall into each category and will factor in expenditure assignment, risk adjustment, and attribution. The specific episodes of care are still under development and will be finalized in 2017 for the 2018 reporting period. A full list of proposed episodes can be found here.

Click here to learn more about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Category Details
During the 2017 MIPS transition year, the Cost category will not be counted toward your overall MIPS composite score, but you will still receive feedback on your practice’s performance. It is in your practice’s best interest to familiarize yourself with the category in 2017 in order to be ready for reporting in 2018. The biggest change your practice will notice from the Value-Based Modifier program is the addition of new care episodes that will help address more specialties with additional applicability. The measures in this category are based on claims submitted by your practice and will not require any additional reporting.

Quality Program Services
Do you need more help navigating the Cost category? Time is running out! Schedule an appointment with your Client Solutions Advisor today to learn more about your practice’s options.

Need more help navigating MACRA? Watch our webinar “MACRA101: The New Quality Payment Program,”
to learn more about the new federal policy changes.

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