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How specialty practices can succeed in MIPS and value-based care


Specialty providers can take steps now to succeed with MIPS and VBC while prioritizing caring for their patients.

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Now in its seventh year, the Merit-Based Incentive Payment System (MIPS) continues to create confusion, especially for specialists. The program can have a big impact on Medicare Part B reimbursements, using the MIPS composite performance score to determine if providers will receive a payment bonus, a payment penalty, or no payment adjustment at all. Adjustments are based on performance in four categories: quality, cost, promoting interoperability, and improvement activities.

The biggest challenge for providers is to report data for at least six quality measures for a minimum number of cases for each calendar year. This poses an additional challenge for specialty providers as most of the measures were designed around the most common point-of-service where Medicare participants receive treatment – primary care. Specialty providers often find themselves force-fitting measures to fit the specialized care they provide. In addition, the benchmarks used to score performance keep raising the bar each year, making it increasingly difficult to earn a high score.

MIPS is one of many government programs focused on improving quality with a focus on value-based care. Programs like MIPS seek to change provider behavior to ultimately improve patient outcomes with the most affordable costs – using penalties to drive that change. To reduce the burden of MIPS, it’s best to make the shift in behavior to support providers in delivering the best patient care – and making compliance with these programs a natural outcome of doing that well.

Specialty providers can take three steps now to succeed with MIPS while prioritizing caring for their patients.

Be proactive about MIPS

To comply, CMS requires a full year of data for a minimum number of patients. If you have not considered your plan for 2024, don’t delay. Your plan for 2024 should recognize that it will be the strictest in the history of the program, including changes to 60 quality measures. It’s imperative to become familiar now with the CMS MIPS final rule released in November. With a requirement to report on at least six clinical quality measures, start by understanding the measures and associated benchmarks that best fit your patient mix.

Note that some clinical quality measures are specialty specific, while other measures need to be selected based on the appropriateness for the care they deliver. Many specialty practices need to incorporate primary care measures into their standard practice to have enough measures. For example, an ophthalmologist who treats patients with complications of diabetes can incorporate the HbA1c lab results into their documentation and get credit for an outcomes-based quality measure. With these considerations in mind, identify at least six measures to target in 2024 that will benefit your patients, and optimize your MIPS score.

Make MIPS part of everyday practice

Each year, the benchmarks have grown tighter, so it is reasonable to expect that will continue. Moreover, the outcomes for providers have shifted from gaining incentives to avoiding penalties – now a minus 9% for Medicare Part B reimbursements. Therefore, it’s imperative that providers make MIPS compliance a team effort by integrating the measures and associated documentation within everyday patient care workflows right from the start of the year. 

After identifying at least six quality measures, consider with all staff, from the front desk to the care team to billing and reimbursement, how best to incorporate each one into day-to-day care delivery and administrative processes. For example, when a patient checks in for care, establish a standard protocol for the front desk staff and medical assistants to update the medication list and document weight and blood pressure. You can leverage the required MIPS functionalities in your 2015 Edition Certified EHR to make sure that your clinical documentation will satisfy your MIPS efforts.

In addition, consider how to make ongoing patient engagement part of your standard practice. For example, invite patients to connect via the patient portal, provide patient educational materials, offer virtual visits as appropriate, and increase proactive outreach for follow-up and preventive care. All these actions improve care and patient engagement while improving scores on MIPS measures at the same time.

Keep an eye on what’s expected in 2024

Even as CMS tightens the MIPS program, they are also actively working to reduce the burden on providers. One avenue is the creation of MIPS Value Pathways (MVPs). These pathways are designed to make it easier for certain specialties, such as orthopedics and neurology, to manage their participation in MIPS. However, not all specialties have an MVP available yet. Providers in those specialties can work with their professional associations to lobby CMS to expand MVPs.

With all the changes and the potential impact on revenue, it’s important that providers stay informed. Many seek guidance from their EHR vendor and organizations that provide consulting expertise and technology tools to streamline compliance. In addition, providers should actively use the CMS’s Quality Payment Program website to stay up to date on MIPS.


For specialty providers, there is a balance to strike with the MIPS program. With upfront planning, providers can implement processes that improve patient care and quality outcomes – and successfully address MIPS performance measures. The data collected by CMS is intended to inform patient-centered best practices that will continually improve clinical and financial outcomes. The more we equip the system to make compliance with government programs a natural outcome of quality care delivery, the better the system will work for everyone, especially patients.

Wayne Singer is Senior Vice President of Business Development at Darena Solutions

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