MIPS Cost Performance Category

Two cost measures are used to evaluate performance in the Cost performance category in the 2019 MIPS performance period. CMS uses Medicare claims data to calculate cost measure performance which means clinicians do not have to submit any data for this performance category.

  • Medicare Spending Per Beneficiary (MSPB)

The Medicare Spending Per Beneficiary (MSPB) measure evaluates solo practitioners and groups on their spending efficiency and is risk-adjusted to account for patients' risk profiles. Solo practitioners and groups are identified by their National Provider Identification (NPI) and Taxpayer Identification Number (TIN) combination. Specifically, the MSPB measure assesses the average spend for Medicare services performed by providers/groups per episode of care. Each episode comprises the period immediately prior to, during, and following a patient's hospital stay. Each beneficiary MSPB episode is attributed to a single TIN-NPI.

The episode is attributed to the MIPS eligible clinician who billed the plurality  of Medicare Part B claims, measured by allowed charges, during the period between the index admission date and the discharge date.

  • Total Per Capita Costs (TPCC)

The Total Per Capita Costs (TPCC) measure is a payment-standardized, annualized, risk-adjusted, and specialty-adjusted measure that evaluates the overall efficiency of care provided to beneficiaries attributed to solo practitioners and groups, as identified by their Medicare Taxpayer Identification Number (TIN). On the attribution logic to TPCC there are 2 steps:

Step 1: If a beneficiary received more primary care services from an individual TIN-NPI that is classified as either a primary care physician (PCP), nurse practitioner (NP), physician assistant (PA) or clinical nurse specialist (CNS) than from any other TIN-NPI during the performance period, then the beneficiary is attributed to that TIN-NPI.

Step 2: If a beneficiary did not receive a primary care service from a TIN-NPI classified as either a PCP, NP, PA or CNS during the performance period, then the beneficiary may be assigned to a TIN-NPI in "Step 2."

Benchmarks

CMS will establish a single, national benchmark for each cost measure. These benchmarks are based on the performance period, not a historical baseline period3 . As a result, CMS can’t publish the actual numerical benchmarks for the cost measures before the start of each performance period. For example, the MSPB benchmark used to determine a MIPS eligible clinician’s 2018 Cost performance category score will be based on CY 2018 claims data. All MIPS eligible clinicians that meet or exceed the case minimum for a measure are included in the same benchmark. Case minimums for each cost measure are identified below.

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