Cost and Quality: The Same Category Weight Doesn’t Mean They Are Equal | Clinical Quality Experts

Our Blog

Cost and Quality: The Same Category Weight Doesn’t Mean They Are Equal

Cost and Quality:  The Same Category Weight Doesn’t Mean They Are Equal

Posted On: June 7, 2021

The CMS CY 2021 Final Rule was released late last year and with it the expected announcement of the ongoing march towards matching the overall score weight of the Quality and Cost categories.  While at first glance this may seem par for the course, it may really be a Trojan Horse when it comes to getting the often lauded but never seen +9% payment adjustment!  To understand why this might be so, we need to break things down a bit:

From the beginning, CMS intended to equalize the performance score weighting of the Quality and Cost categories.  In 2017, the first year of MIPS, Quality was the heavyweight category due to its possible 60-point impact on the overall score while Cost was not weighed at all.   Over the next three performance years, Quality has seen reduction in its score weight and Cost impact has increased.  For 2021, there is a 20-point difference between the two, with Quality worth 40 points and Cost worth 20.  2022 will see each category settle into its final weight of 30 points each.  Because of the gradual step-up/step-down method to equalize the score, the consequences of it may be easy to miss.

One such consequence is that if you are unable to qualify for any of the Cost measures then CMS will redistribute the weight of the Cost category to Quality, launching the possible Quality score all the way up to 60 points.  If you have not prepared for this possibility and your Quality scoring is not optimum, it will be hard to meet the performance thresholds necessary for that positive adjustment for 2021 or any other performance year going forward.  Considering that you will not know if your Cost weight must be adjusted until after a performance year has ended means that you need to be strong out of the gate…just in case.

Perhaps CMS intended this?  Certainly, high quality care at low cost is the ultimate objective of the Quality Payment Program agenda.  A worthy goal, but how exactly do you prove it and more importantly, succeed at it?  The Quality category, although complicated with its decile scoring and benchmarking, is straightforward in its methodology; choose your measures, perform the steps, get a score.  There is some semblance of control in how well you do with your Quality measures, and you can revise your processes mid-year if you see a deficiency.  Alternatively, the Cost category can seem somewhat enigmatic and relies upon complicated algorithms to score eligible providers.  Only after your claims are assessed by CMS can your score be calculated; therefore, you are not provided your feedback until well into the next performance year and by then it may be too late to utilize that information to any degree of impact.  Reducing the weight of a category that is controllable in “real-time” and increasing it for a category that provides delayed feedback can be a real positive payment adjustment roadblock.

Which begs the question…who will perform the analysis and provide recommendations based on the feedback?  Is there anyone in your office that understands the scoring process?  If you have not designated a point of contact for this task in the past, it may be time.  Another solution is to onboard with a CMS Qualified Entity, or QE.  A QE uses Medicare data to produce and disseminate reports on provider performance.  Services and fees will vary as there are quite a few Qualified Entities available.  You can learn more about Qualified Entities here:  CMS Approved Qualified Entities

While all the MIPS performance categories are important, Cost and Quality have been linked to each other beyond just metaphorical ideology.  Understanding how one affects the other is key to obtaining the best performance score possible.


Contributed by :
Lora Woltz

With over 30 years working in healthcare, Lora Woltz is a Certified Ophthalmic Assistant and Application Support Specialist for health insurance referral and eligibility management, as well EHR software. Lora is an expert in compliance support for CMS incentive programs ranging from early Meaningful Use to present day MACRA.