How to Get Better While Being the Same

William HymanWilliam A. Hyman
Professor Emeritus, Biomedical Engineering
Texas A&M University,
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I listened to an interesting webinar that was promoted here on the ABCs of the QPP: Understanding the Proposed 2019 QPP Rule. The replay is available along with other webinars (with which I have no affiliation). The use of the term “Understanding” in the title is optimistic since the proposed rule is astoundingly complex, as might be indicated by it’s over 1400 pages.

One thing that was reinforced to me was that scoring schemes are inherently arbitrary and subject to manipulation. As subpart values change, the passing grade increases, and activities move in and out of the grading scheme, and subject to the complex calculations, the webinar urged viewers to make sure that they knew where they were and what they needed to do differently to have the same result or improve in 2019, subject to the later final rule. Improve here is used in the narrow sense of having a better score and payment outcome, which may or may not have anything to do with improving patient care.

There were a number of observations of how you could end up worse, the most notable being the increase in the basic performance threshold score from 15 to 30, and 70 to 80 for exceptional performance. But I don’t think I heard as much discussion of how you might get better without doing anything differently. Here, by analogy, is how that could work.

Suppose a score calculation in 2018 has four parts that are unequally weighted, eg A(50), B(20), C(10) and D(20). Suppose each part has a maximum of 100 points and that you score on each part 80, 60, 75, 50 respectively. Then your composite score is 70 (rounded up). Now suppose in 2019 your scores in each part remain the same at 80, 60, 75, 50, but the weighting changes so that D is dropped from the score and the remaining weights changed to 60, 40, 10. Note here that A is now relatively more important as in the “MIPS Cost” weighting increasing from 10 to 15%. Here D might have become a yes/no question such as “Security risk analysis” changing to required but no longer scored. Now your composite score is 80, so you improved from the previous year’s score of 70 even though you did everything the same. Well done!

Now one might argue that the 80 better reflects your actual impact on patient care, ie you are actually better than the previous score of 70 indicated, meaning that you were unfairly rated in 2018. One might also argue that the hard work by CMS/ONC has resulted in a scoring system that is actually more meaningful beyond having improved your score. It would be nice if there was or will be any data to show this to be the case, ie that the scoring manipulations actually are related to improved patient outcomes and/or reduced cost. In the meantime, enjoy your new success.