Will Episode-Based Care Become Part of MIPS?

Thursday, October 26, 2017 | Larry Sobal

Will Episode-Based Care Become Part of MIPS?



Lately my head has been filled with thoughts related to MIPS, MACRA and everything QPP. Why is that, you ask?  Let me count the reasons:

1. For starters, 2017 is the first year of physicians participating in MIPS (Merit-based Incentive Payment System) and we are in the final stretch of organizations collecting their data and determining whether their pick your pace option will be submitting nothing, submitting a minimal amount of data, submitting for 90 days (partial year) or submitting data for a full year.

2. Here we are almost to November and CMS has still not issued an official set of “final rules” in response to the 2018 MACRA Proposed Rules that came out in July. There are a lot of significant issues to be clarified and not much time until January 1st when the second year of MIPS begins.

3. And let’s not forget that just recently MedPAC recommended to Congress that it eliminate the MIPS payment track in MACRA, so many organizations are now questioning whether MIPS will be around in the long run.

Each one of those is a big deal, but there is another recent MIPS-related announcement that really got my attention. CMS has announced it is now conducting field testing for eight episode-based cost measures for MIPS before considering their potential use in the cost performance category of MIPS. All I can say is “Wow.”

Just when we thought we weren’t sure where episode payment models stood with CMS, this comes along—very interesting. Particularly in light of the August announcement that CMS was cancelling the mandatory CV episode payment models and the rumors of a pending relaunch of the voluntary Bundled Payment Care Initiative (BPCI).

So what exactly is this test program that links bundled payments with MIPS? What we know is that there is a one month field testing period going on right now in which clinicians and clinician groups who are attributed to the measures being tested will have the opportunity to view a confidential report with information about their performance. The survey for collecting your feedback on the measures opened October 16, 2017 and will close at midnight on November 15, 2017. The survey can be found at this web address

CMS will test the following eight episode-based measures:

1. Elective Outpatient Percutaneous Coronary Intervention (PCI)

2. Knee Arthroplasty

3. Revascularization for Lower Extremity Chronic Critical Limb Ischemia

4. Routine Cataract Removal with Intraocular Lens Implantation

5. Screening/Surveillance Colonoscopy

6. Intracranial Hemorrhage or Cerebral Infarction

7. Simple Pneumonia with Hospitalization

8. ST-Elevation Myocardial Infarction with PCI

Clinicians and clinician groups who are attributed at least 10 episodes for one or more of these eight measures will have an opportunity to view a confidential report with information about their cost measure performance. Others can view a mock report and supplemental documentation on the measures on the CMS website. As part of the experiment, CMS has created reports for around 17,000 medical practices based on claims data from June 1, 2016 to May 31, 2017.

CMS is going to continue to look for ways to incorporate incentives for episode payment models into its various programs.


Acumen, a CMS partner, will distribute confidential field test reports to group practices and solo practitioners through the CMS Enterprise Portal, which CMS has used for distributing Quality and Resource Use Reports (QRURs). Please note that field testing of new cost measures is separate from measures reported in your QRURs, which you may also receive at about the same time. The QRUR guide may also be used to set up an Enterprise Identity Management (EIDM) account. 

Supplemental documentation about the measures will be posted publicly on the CMS website. Acumen is seeking feedback from all stakeholders on the following:

  • Draft measure methodology for each measure 
  • Draft measure code lists with specifications for each measure
  • Mock field test report 
  • Fact sheet with an overview of field testing 
  • Frequently Asked Questions (FAQ) document 

Accessing your field test reports requires that you have an EIDM account and that you have access to a “Physician Quality and Value Programs” role within that application on the portal. If you do not have an EIDM account, you can set one up and get access to a “Physician Quality and Value Programs” role in preparation for accessing your field test report by using this guide

Field testing presents an opportunity for affected clinicians and other stakeholders to provide feedback, which CMS will use to consider potential measure refinements. All feedback questions in the survey will be optional so you may answer as many or as few questions as you like. The survey will also have an option for attaching a PDF or Word document in addition to or instead of completing the questions. 

If you would like more information, CMS will also hold two national provider calls — Oct. 30 at noon to 1:30 pm EDT and Nov. 2 at 3:30 p.m. EDT — to provide additional information on the field testing.

This field test raises some interesting questions. Although the MACRA law did allow CMS to waive the cost measure for two years, physicians have grown increasingly concerned that CMS still isn’t clear how it will evaluate them on cost. Plus, the current proposal to delay “cost” as a MIPS category means that providers will need to be prepared to go from cost being weighted in MIPS scoring as 0% in 2017 and 2018 to being weighted 30% in 2019 – a daunting task considering physicians still don't know how they will be assessed on costs and are not confident in the attribution methodology that associates costs to physicians or Tax ID numbers (TINs).

Field testing also adds new intrigue, and confusion, to MACRA and MIPS. Here’s what I think. CMS is going to continue to look for ways to incorporate incentives for episode payment models into its various programs. Since MACRA is technically voluntary, this fits with former HHS Secretary Price’s (and CMS administrator Seema Verma’s) vision of having voluntary participation in episodes. Combined with the likely announcement of BPCI Advanced, incorporating episodes in MIPS will then allow CMS to offer voluntary episode models to both hospitals and physicians. What this tells me is that if I were you (a hospital or physician) I would be getting well versed in your episodic performance data right now, something MedAxiom can help you with easily. How it will all play out is another mystery in our rapidly (and unpredictably) changing health care industry, but being aware of your performance and being prepared puts you in the best position. Stay thirsty (for knowledge, data and clarity) my friends!



Illustration: Lee Sauer


Larry SobalLarry Sobal is Executive Vice President and a Senior Consultant at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and health insurance. Larry consults, writes and presents on topics relevant to transforming physician practices and health systems. His weekly blog post comes out on Thursdays and can be accessed at www.medaxiom.com.


About the Author
Larry Sobal

Larry Sobal, MBA, MHA, is CEO of a yet-to-be-named cardiology practice which is transitioning from employment to an independent physician group effective January 1, 2019. He has a 37-year background as a senior executive in physician practices, consulting, medical group leadership, hospital leadership and health insurance.

To contact, email: larry.sobal@gmail.com

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