Damned if We Do, Damned if We Don't: The Tricky MIPS Toss-Up • Posts by EIM | Evidence In Motion Skip To Content

Damned if We Do, Damned if We Don’t: The Tricky MIPS Toss-Up

January 30, 2020 • Advocacy • Heidi Jannenga

When it comes to the game of MIPS, there are no clear winners. There are pros and cons to participating—and pros and cons to opting out. And because MIPS is fraught with unknowns, it’s almost impossible to perform an accurate cost-benefit analysis prior to making that choice. For example:

  • We don’t know how many participants will surpass the performance threshold in any given reporting year.
  • Therefore, we don’t know how much money CMS will award to successful participants.
  • We don’t know how individual performance correlates to payment adjustments, because performance is rewarded on a sliding scale that changes each year.
  • We don’t know whether or not participation will eventually become mandatory for everyone.

The line only gets blurrier from there, because MIPS isn’t the only CMS initiative that’s missing crucial context. We also don’t know how much CMS’s impending reimbursement cuts will affect PT practices, which makes it awfully difficult to steer PTs away from MIPS when it could be a potential revenue booster—and perhaps, eventually, a permanent requirement.

So, for rehab therapists, MIPS is a tricky toss-up—a “damned if we do, damned if we don’t” kind of situation. But, we all have to make a choice one way or the other—and having a basic understanding of the potential ramifications will help you make better, more informed decisions. With that in mind, let’s break it all down.

Damned if We Do: Reasons Not to Participate

Let’s start with the not-so-great stuff—the reasons why MIPS participation might not be a worthwhile endeavor for rehab therapists (not yet, at least).

The payout won’t necessarily cover the cost of participation.

MIPS participation comes at a cost: end of story. You might pay that cost to a Qualified Clinical Data Registry (QCDR) vendor or, if you choose to take reporting into your own hands, you might pay it in employee hours—but at the end of the day, you have to dedicate clinic resources to MIPS participation.

A participation cost wouldn’t be so bad if you knew that you could recover your investment somewhere down the line, but at this point, that’s not necessarily the case. The payment adjustments awarded thus far have been minimal at best. In 2017, the highest adjustment awarded (and this includes the bonus for exceptional performance) was 1.88%. In 2018, positive adjustments topped off at 1.68%. For some clinics, this paltry incentive would barely cover the cost of participation.

Participation adds to therapists’ already heavy workloads.

While third-party vendors can help minimize the burden of MIPS, you can’t get around the fact that MIPS participation means more reporting—which means more boxes to check, more hoops to jump through, and more opportunities for things to go wrong. Therapists already spend inordinate amounts of their day wading through rigorous documentation requirements; when are we supposed to find the time to check these new tasks off our to-do list? It also doesn’t help that the burden of MIPS participation grows exponentially when therapists aren’t equipped with the right tools to collect and report data.

MIPS puts rehab therapy employers in a potential legal pickle.

Speaking of therapists: An unintended consequence of the MIPS program is that it opens the door to potential human resource and legal problems for clinic owners. At its core, MIPS participation isn’t a clinic-wide endeavor; it’s an assessment of individual providers. That’s why CMS only requires participation on an individual basis; group participation is always optional (but even when therapists elect to report as a group, the resulting adjustment follows individual NPIs).

So, what happens if a clinic isn’t willing to support staff therapists who are mandated—or who choose—to participate in MIPS? Worse yet: What if the clinic and mandated providers are ignorant to the fact that they are required to report, and thus, don’t participate. On the flipside, maybe a clinic does the right thing and encourages therapists to participate, but isn’t able to provide them with the tools they need to succeed (e.g., a reporting software), and they end up incurring a penalty that—as previously mentioned—will follow their NPI.

Can you—and by extension, the clinic—be held liable? If one of those therapists wants to get a job at another clinic, but can’t get hired because of that negative MIPS adjustment, could he or she sue? Could a clinic legally—not to mention ethically—hire or fire a PT based on his or her MIPS adjustment? Is it legal to ask potential new hires about their MIPS status and perhaps adjust their pay accordingly? These are all tough questions that I don’t think many people are really thinking about yet—and it may behoove the industry to hold off on opt-in participation until we have solid answers.

Damned if We Don’t: Reasons We Have to Participate

MIPS participation clearly isn’t a sunshine and roses kind of deal—but perhaps therapists should grit their teeth and do it anyway. Here’s why:

MIPS is currently the only way to offset looming cuts to Medicare reimbursements.

As I mentioned above, physical therapists are facing some serious payment cuts in the coming years. In 2021, the industry-wide 8% cut to payments for PT and OT services will take effect, and 2022 will usher in the 15% reduction on assistant-provided services. To make up for those losses, outpatient therapists must capitalize on every possible money-making opportunity—and MIPS is one of them. In fact, MIPS might be therapists’ only ticket to recouping some of the revenue CMS plans to take away. And don’t get me wrong; I do recognize that historically, the MIPS payout has been small—but I’d counter by saying that, well, something is better than nothing.

Besides, I have a hunch that it’s not always going to be that way. CMS has raised the MIPS performance threshold each year, making it increasingly difficult for participants to satisfy the reporting requirements. In theory, that means more clinicians will fail, which should allow for higher incentive payments to those who participate successfully. As long as you have the right tools in place, it’s totally feasible to earn a positive adjustment—even if it’s not an earth-shaking sum.

There’s a good chance MIPS participation will eventually become mandatory.

CMS is a creature of habit. It may adjust its tactics from year to year, but its strategy and goals remain fairly consistent. And right now, those goals center on reducing costs and improving care. Quality programs—whatever form they may take—seem to be CMS’s favorite mechanism for pursuing its goals.

First, there was PQRS, a quality reporting system that actually stuck around long enough to be grandfathered into MIPS. Then, there was functional limitation reporting (FLR)—a short-lived program that was supposed to help demonstrate the value of rehab therapy. Now, we have MIPS: an overly complicated and absurdly dense quality program.

What I’m getting at is that I don’t think MIPS is going away. In fact, I think it’s very possible that MIPS will become mandatory for most of the medical community. But, even if MIPS goes the way of FLR or PQRS, another program will surely surface and take its place. Therapists might as well get in the groove of reporting and learn how to excel at this now—before the stakes get even higher. Even if you don’t take home a large payment adjustment, wouldn’t you rather get your footing now than sit on your hands and wait for mandated participation?

MIPS data provides a valuable advocacy tool.

PTs deserve a spot at the greater healthcare table—but we don’t always get one. MIPS could be our way of getting that seat—and showing everyone, from physicians to the CMS administrator, that our voice, services, and expertise are truly valuable.
MIPS may have been designed around physicians, but we can still participate meaningfully—whether we’re doing so in single-provider clinics or big enterprise organizations. In fact, CMS has put special conditions in place to help small practices succeed. Small practices can earn six bonus points for submitting at least one measure. They also will earn double points in Improvement Activities—essentially halving the reporting work in that category.

Final Thoughts

MIPS isn’t exactly an ideal quality program. It’s not a financial slam dunk; participation comes with a degree of burden; and there is a lot that we don’t know about how it will affect PT clinics. But, at its core, MIPS isn’t all that different from the programs we’ve seen—and conquered—in the past. Is it really so unrealistic to think that we can’t do it again? To be totally frank, I’m beginning to think that we’ll be more “damned” if we sit on our hands and refuse to report. We must participate in the greater health care arena to the fullest extent possible—and in my opinion, that includes participating in MIPS. I won’t gloss over MIPS’s drawbacks and pretend that they don’t exist—but at this point, the upside is too great to ignore.
All that said, I’m open to conversation. Are you going to participate in MIPS in 2020? How do you feel about your decision—and the program in general?

Heidi Jannenga

Heidi Jannenga, PT, DPT, ATC/L, is the president and co-founder of WebPT, the leading practice management solution for physical, occupational, and speech therapists. Heidi leads WebPT’s product vision, company culture, and branding efforts, while advocating for the physical therapy profession on a national scale. She co-founded WebPT after recognizing the need for a more sophisticated...

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