Quality Payment Program: Merit-Based Incentive Program (MIPS)
October 2017
In Partnership with Alliant QualitySouth Carolina Office of Rural HealthCenter for Practice Transformation
CMS Quality Payment Program Website:
https://qpp.cms.gov
MACRA/Quality Payment ProgramMedicare Access and CHIP Reauthorization Act of 2015
• New framework of physician/clinician reimbursement – rewards better care (value) rather than more care (volume)
• Repeals and replaces sustainable growth rate (SGR)• Primarily still based on fee-for-service architecture• Consolidates Medicare quality programs
– Meaningful Use– Physician Quality Reporting System (Quality)– Value Based Payment Modifier Program (Cost)
Quality Payment Program Medicare Clinician Reimbursement
MIPS (Merit-Based Incentive Program):• Based on fee-for-service • Performance score based on
“value”• FFS payment adjusted based on
performance score
APMs (Alternate Payment Models):• Moves to population-based and
episode-based payment• Requires shared two-sided risk• Incentives for organizations to
move towards APMs (bonus)
QPP
MIPS
MIPS
APM
APM
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-LAN-PPT.pdf
Merit-Based Incentive Program Each physician or eligible professional or group will receive a composite performance score: 0-100; score will determine reimbursement
Quality
60%
Improvement
Activities
15%
Cost
0%
Advancing
Clinical
Information
25%
Final Score
(0-100)
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-LAN-PPT.pdf
MIPS
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-LAN-PPT.pdf
Transitional Year: - Avoid Negative
Adjustment -3 points
- Eligible for Positive Adjustment - 4-69 points
- Eligible for bonus > 70 points
2017Transitional Year
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-ACI-and-IA-presentation.pdf
2017Transitional Year
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-ACI-and-IA-presentation.pdf
MIPS• Quality: 6 performance measures (1 outcome); or one
specialty-specific or subspecialty-specific measure set; (PQRS)
• ACI: Base Measures - 5/4 core measures of EHR functionality; Performance Measures - how well you are using EHR; bonus points (MU)
• Cost: Claims-based; total per capita cost per attributed beneficiary & Medicare spending per beneficiary; Performance Year 2017 0% to 30% by 2019 (VM)
• IA: 92 practice improvement activities – high and medium activities; 1 high or 2 medium activities for small practices; PCMH recognition receives full points
Participation
Reporting
Clinical Quality
Action• Select Measures: select 6 measures with 1 outcome measure or high
priority measures – What can you measure and report?– Align with other quality measurement priorities or experience
• PQRS• MU CQMs• EHR reports• Priority Populations• HEDIS Measures
• Decide on Submission Method– How will you report/submit?
• QCDR• EHR Vendor• Qualified Registry• Claims
• Understand measure specification• Focus on high performing measures • Use QI methods to drive improvement
– Analyze and set goals and test improvement strategies
Select Measures
Clinical Quality
• Must select and report on 6 clinical quality measures from list of 271 measures -https://qpp.cms.gov/mips/quality-measures
• 1 of 6 measures must be an outcome measure; if an outcome measure is not available that is applicable to your specialty you can select another high priority measures
• Data completeness: must report on at least 50% of possible data
Selecting Measures
https://qpp.cms.gov/mips/quality-measures
Selecting Measures
Source: https://qpp.cms.gov/mips/quality-measures
Selecting Measures
Source: https://qpp.cms.gov/mips/quality-measures
Measure
Source: https://qpp.cms.gov/mips/quality-measures
Decide on Submission Method
Reporting
Understand Measure Specifications
Focus on High Performing Measures
Scoring
Scoring
Scoring
Benchmarks
Benchmarks
Source: https://qpp.cms.gov/about/resource-library
Benchmarks
Scoring
Scoring
Use QI Methods
Quality Improvement
• Quality Improvement –formal approach to the analysis of performance and systematic efforts to improve it– Ensures changes are for
the better/positive
• Improvement Science– Model for Improvement
– Lean/Six Sigma…
Measuring Quality:“Continuous Quality Improvement”
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the goal of CQI
Model for Improvement
• 3 “Powerful” Questions– What are we trying to
accomplish – Set Goal/Aim– How will we know that a
change is an improvement – Select Measures
– What changes can we make that will result in improvement –Improvement Strategies
• Test the change/Implement improvement strategy using PDSA cycle
Improvement - Clinical Care
• Setting: Large Internal Medicine Practice
• Goal: Improve lipid screening for patients with diabetes
– 55% of patients had total cholesterol tested annually
– Approximately 68% were prescribed statins
– Average total cholesterol = 185 mg/dl
– Average LDL = 99 mg/dl
PDSACycle 1
Plan: Front Desk will identify all patients with diabetes and check diabetes flow sheet for date of last LDL test
Do: Eastside front desk examined problem list for all scheduled patients with diabetes and flowsheet for date of last LDL test; date of test noted on schedule; Week of October 4th
Study: 22/30 patients had LDL test listed on schedule; 17/30 received needed LDL test
Act: Provide daily feedback to front desk staff; implement incentive program
Percent of Patients with Total Cholesterol Tested Yearly
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Front desk fidelity
Advancing Clinical Information
Action Items
• Identify applicable measure set – 5 required measures vs. 4 required measures based
on EHR edition
• Review base measures
• Select and assess performance measures you will be reporting
• Review bonus opportunities
• Align with IA activities and other quality improvement activities
• Take steps to improve performance
Identify Measure Set
Measure Sets
Two measure set options for reporting. The option you use depends on the edition of your EHR• Option 1: ACI Objectives and
Measures– Technology certified to the 2015
Edition; or a combination of technologies from 2014 and 2015 Editions that support these measures
• Option 2: ACI Transition Objectives and Measures
– If you have technology certified to the 2015 Editions; or technology certified to the 2014 Edition; or a combination of technologies from the 2014 and 2015 Editions
To determine which measure set you should use, use the following lookup tool: https://chpl.healthit.gov/#/search
Review Base Measures
Base Measures
• Must fulfill all the requirements of all base measures to receive base score
• If all measures are not met than you will receive 0 points in the performance category
• To receive base score (50% of overall score), must affirm a security risk analysis and at least 1 in numerator for the remaining measures
Base Measures
Base Measures Transition Measures
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-ACI-Deep-Dive-Webinar-Slides.pdf
ACI Measure Specifications
Source: https://qpp.cms.gov/measures/aci
ACI Measure Specifications
Select Performance Measures
Performance Measures
Performance MeasuresTransition Performance Measures
Performance Measures
• Performance score is calculated by using the numerators and denominators submitted for each performance measure
• Total available performance score is 90%
• Performance score is determined by the performance rate for each measure
• All but two performance measures are worth 10% points
Example: EC submits a performance rate of 85/100 patients received a summary of care; Performance rate: 85% which would result in 9% points for this measure
Review Bonus OpportunitiesAlign with Improvement Activities
Bonus Measures
• Bonus points can be achieved by
– reporting “yes” to 1 or more additional public health and clinical data registries
– Reporting “yes” to the completion of at least 1 Improvement Activity using CEHRT
Bonus Measures
Bonus Measures Transition Bonus Measures
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-ACI-Deep-Dive-Webinar-Slides.pdf
ACI/PIA Bonus Points
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-ACI-and-IA-presentation.pdf
Base Scoring
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-ACI-Deep-Dive-Webinar-Slides.pdf
Performance Scoring
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-ACI-Deep-Dive-Webinar-Slides.pdf
Bonus Point Scoring
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-ACI-Deep-Dive-Webinar-Slides.pdf
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-ACI-Deep-Dive-Webinar-Slides.pdf
Reweighting
• To have ACI category to be reweighted to 0%, ECs/groups must meet the following:– Insufficient Internet Connectivity– Extreme or Uncontrolled Circumstances– Lack of control over the Availability of CEHRTMust submit application to CMS
• To qualify for automatic reweighting:– Hospital-based MIPS clinician– PA– NP– CNS– CRNA– Clinician who lack face-to-face interactions with patientsACI Category will be reweighted at 0% with the 25% assigned to the Clinical Quality Category
Group Reporting
• Groups report ACI measures as a group not by individual clinician
• Hospital-based clinicians do not have to included in the group calculation for ACI
Improvement Activity
Action• Create at Improvement Team• Review list of 92 eligible clinical practice improvement
activities• Select focus/activity
– What are you currently doing?– What resources are available to support CPIA?– Where your pain points?
• Prioritize activities that involve use of EHR• Apply QI methods
– Set Aim– Select measures– Select improvement strategy– Test strategy
Practice Improvement Activities• Practices must attest to the completion of
approved practice improvement activities for a minimum of 90 days
– 92 approved practice improvement activities
– Activities rated as either high and medium activities
• Small practices must complete 1 high or 2 medium activities
– 15 or fewer clinicians attached to one Tax ID #
– Rural or health professional shortage area
• PCMH or PCSP recognition maximum points
• Activities that involves CERHT gets bonus scoreSource: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-ACI-and-IA-presentation.pdf
Create Improvement Team
Team Sport
Improvement Team
• Form a team – 3-6 members (2-3 if small practice)
– Roles:
• Provider champion
• Day-to-Day leader
• System leader
• IT leader
• Other (Front Desk Staff)
– Meet 2x per month to get started – regular meetings
– Accountable for deliverables
– Practice transformation and clinical practice improvement CANNOT be done by one person
Select Improvement Activities
Resources: Patient Self-Management Implementation Guide: http://cepc.ucsf.edu/sites/cepc.ucsf.edu/files/Action_Plans_14-0602.pdf
Self-Management Support: http://www.improvingchroniccare.org/downloads/selfmanagement_support_toolkit_for_clinicians_2012_update.pdf
Initial Training Slide Deck is available from SCORH upon request
Attestation• Start Date of Improvement Activity• Baseline Measurement (if applicable)
– 55% of Schedule II drugs were checked in Drug Monitoring program (IA_PSPA_6)
– 10% of patients with CHF had a completed SM Plan (Action Planning Tool) (IA_BE_17)
• Listing and description of improvement strategies (PDSA cycles)Care Coordination (IA_CC_7)– Conducted initial staff training on 10/6/17 on care coordination – Developed training topic list and training schedule– Provided follow-up training on Transitional Care Management on 12/3/17
• Re-measurement/Improvement (if applicable)– 80% of Schedule II drugs were checked in Drug Monitoring program
(IA_PSPA_6)– 24% of patients with CHF had a completed SM Plan (Action Planning Tool)
(IA_BE_17)– 3 Trainings on Care Coordination held
Apply QI Methods
Model for Improvement
• 3 “Powerful” Questions– What are we trying to
accomplish – Set Goal/Aim– How will we know that a
change is an improvement – Select Measures
– What changes can we make that will result in improvement –Improvement Strategies
• Test the change/Implement improvement strategy using PDSA cycle
R&D
Rip-Off & Duplicate
Change Packages/Tools…
http://www.safetynetmedicalhome.org/change-concepts/empanelment
Scoring
Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-ACI-and-IA-presentation.pdf
Scoring
Cost
Action Items
• Review and understand measures• Explore attributed beneficiaries; who belongs to
you– Who received most of the primary care services from
you or your group?
• Review your QRUR Report• Coding, coding, coding…code for severity (HCC
risk adjustment - RAF scores)• Develop and implement strategies to improve
coding of severity and includes all conditions and for efficient management of attributed patients
Review Measures
Measures
• Medicare spending per beneficiary– 3 days before and 30 days after an inpatient
hospitalization– Attributed to the group or solo practitioner
providing the plurality of Part B services during the hospitalization
• Total Cost per attributed beneficiary– per capita Medicare Part A and Part B costs that
are payment standardized, risk adjusted, and specialty adjusted
Understand Attributed Beneficiaries
Patient Attribution
• Medicare has data on where patients were seen, who saw them, and what kind of clinician saw them
• CMS identifies all primary care visits in a year
• Primary care=PCP (MD/DO/NP/PA) visit with E&M code in office or other other non hospital setting.
• TIN with plurality of primary care visits=Attribution to that TIN
Where do I access the report?
QRURs are available at the TIN level and
accessed via the CMS Enterprise Portal
(portal.cms.gov) by authorized individuals of
solo or group practices
2017 Value Modifier
Per Capita Costs for All Attributed Beneficiaries
Contact Information107 Saluda Pointe Dr
Lexington, SC 29072
Phone: 803-454-3850
Fax: 803-454-3860
http://www.scorh.nethttp://twitter.com/scruralhealthhttp://www.facebook.com/SCORHhttp://www.youtube.com/user/scruralhealth