The Cost category is undergoing notable updates, particularly with the introduction and refinement of episode-based cost measures. These measures are designed to focus on specific clinical conditions and procedures, offering more precision in how healthcare providers are assessed for cost efficiency.
Episode-Based Cost Measures: A Quick Overview
Episode-based cost measures evaluate the cost of care during a specific clinical episode, such as a surgery or the treatment of a chronic condition. These measures focus on the costs related to a discrete period of care, rather than broad categories like total per capita cost. By focusing on a specific event or condition, CMS aims to provide a more accurate picture of the cost efficiency within a clinician's domain of expertise.
Category Weighting for 2024 and 2025
For the 2024 and 2025 MIPS performance years, the Cost category will continue to carry significant weight, accounting for 30% of your total MIPS score. This means that improving performance on Cost measures, including episode-based ones, can have a substantial effect on your overall MIPS score. Given that the Cost category is assessed based on Medicare claims data with no additional reporting requirements, it’s essential to focus on providing cost-efficient care during key episodes.
What’s New in Episode-Based Measures for 2024 and 2025?
CMS continues to expand and refine episode-based measures in response to emerging clinical priorities and feedback from the healthcare community. These measures are particularly important for specialties where certain high-cost procedures or treatments dominate practice patterns.
Recent Additions for 2024:
1. Cardiac Valve Surgery Episode: This measure evaluates the total cost of care related to cardiac valve surgeries, a high-cost area that is crucial for cardiology practices. Costs associated with inpatient, outpatient, and post-acute care settings are included, providing a comprehensive look at the financial impact of these complex procedures.
2. Hip Fracture Episode: A new measure targeting the cost of care for patients undergoing hip fracture repair. With an aging population and increasing rates of these injuries, this episode-based measure has been added to help orthopedic practices and hospitals understand their cost drivers.
3. Invasive Treatment of Osteoarthritis of the Knee: This measure captures the cost for knee replacement surgeries and other invasive treatments. As joint replacement procedures continue to rise, this measure will be important for specialists focused on musculoskeletal health.
4. Lumpectomy for Breast Cancer Episode: This measure examines the costs associated with*breast cancer lumpectomies, focusing on both the surgical episode and the post-operative care, including any follow-up treatments like radiation therapy.
Attribution: Ensuring the Right Providers Are Measured
For 2024, CMS has made improvements in the attribution models used to assign episode-based measures. Attribution determines which clinician or group of clinicians is held accountable for the costs of care during an episode. This refinement aims to provide more accurate attribution, ensuring that clinicians who contribute most to an episode's cost are the ones being measured.
For example, in the case of the new cardiac valve surgery episode, surgeons and interventional cardiologists would be the primary clinicians evaluated for the cost, with careful attention paid to the role of post-acute care providers.
Maximizing Your Performance in the Cost Category
Given that Cost now accounts for 30% of your total MIPS score, and episode-based measures are becoming more prominent, it’s crucial to optimize your performance in this area. Here are key steps to ensure you are ready for these changes:
1. Understand the Episode-Based Measures that Apply to Your Practice
If you’re in a specialty that deals with high-cost procedures, such as orthopedics, cardiology, or oncology, make sure to review the relevant measures and understand how your services are being evaluated. For example, if you’re a cardiologist, focus on understanding the nuances of the cardiac valve surgery episode, including costs related to surgery, follow-up care, and any complications.
2. Coordinate Care to Manage Costs Across an Episode
Many episode-based measures involve multiple care settings—hospitals, outpatient centers, and rehabilitation services, for example. To succeed, you need to coordinate effectively with other providers to ensure that patients receive high-quality care without unnecessary costs. This is especially relevant in episodes like the hip fracture or lumpectomy measures, where post-acute care plays a significant role.
3. Leverage Historical Data to Identify Opportunities for Improvement
Use Medicare claims data from previous years to analyze your performance on specific episodes. Identify areas where your costs are higher than expected, and look for ways to reduce waste, avoid unnecessary tests or treatments, and streamline care delivery. For example, if you frequently perform knee replacements, analyze past episodes to find opportunities to reduce post-surgical costs while maintaining high-quality outcomes.
4. Stay Informed About Measure Updates and Adjust Your Strategy
CMS updates and refines measures each year, so it’s essential to stay current. Regularly review the new and updated episode-based measures, and adjust your strategy to ensure that you’re targeting the highest-impact areas for your practice.
The Growing Importance of Episode-Based Cost Measures
As CMS continues to refine and expand the use of episode-based measures in MIPS, it’s clear that cost efficiency in specific clinical areas will play a major role in determining your overall MIPS score. By understanding these measures, coordinating care effectively, and identifying opportunities to lower costs, clinicians can position themselves for success in the 2024 and 2025 performance years.
Episode-based measures offer a clearer path for clinicians to improve their cost scores by focusing on their most resource-intensive services. By mastering these measures, you not only protect your MIPS score but also align with broader trends toward value-based care. Reach out today to see if we can help! 803-205-2544
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