MIPS: Quality Measures and Scoring

Sam Ross, QPP Advisor and Manager Quality Payment Program of Illinois

July 19th, 2017

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Agenda

Merit-based Incentive Payment

System at-a-glance

Quality performance category measures and scoring

NOTE: Information in this presentation applies to rules for the 2017 performance year. Future years will have modifications established through additional rulemaking.

Merit-Based Incentive Payment System

(MIPS)

MIPS Eligible

Individual clinicians or groups exceeding the low-volume

threshold ($30,000 to Medicare Part B AND providing care for

more than 100 Medicare patients over 12-month period)

Check eligibility at https://qpp.cms.gov

Enter NPI into search box

Click Check NPI button

Review individual and group eligibility

PhysiciansPhysician Assistants

Nurse Practitioners

Clinical Nurse Specialists

Certified Registered

Nurse Anesthetists

GROUPINDIVIDUAL

Individual vs. Group

Individuals are included in MIPS based on claims for single NPI at each associated TIN

Individuals may be required to report at multiple TIN

MIPS score based on performance of single NPI at associated TIN

Payment adjustment based on performance of single NPI at associated TIN

Groups are included in MIPS based on claims for all NPI billing to TIN

Groups must report for all eligible clinicians billing to TIN (individually or in aggregate)

If reporting in aggregate, group receives MIPS score based on performance of all members

If reporting in aggregate, all members receive same payment adjustment based on group MIPS score

MIPS Excluded

Below the low-volume threshold

• Medicare Part B allowed charges less than or equal to $30,000 a year

OR• See 100 or fewer

Medicare Part B patients a year

Newly-enrolled in Medicare

• Enrolled in Medicare for the first time during the performanceperiod (exempt until following performanceyear)

Significantly participating in

Advanced APM*

• Receive 25% of your Medicare paymentsthrough an Advanced APM

OR• See 20% of your Medicare

patients through an Advanced APM

* Refer to https://qpp.cms.gov/apms/overview for a list of 2017 Advanced APM

Eligible clinicians and groups may be excluded from MIPS reporting

MIPS Concepts & Categories

Moves Medicare Part B clinicians to performance-based payment system

Provides clinicians with flexibility to choose the activities and measures

that are most meaningful to their practice

Combines PQRS, Value-Based Modifier and EHR Incentive (Meaningful Use) into one system with four categories

Quality (replaces PQRS), Cost (replaces Value-Based Modifier), Advancing Care Information (replaces Meaningful Use)

Improvement Activities is a new concept

Quality CostImprovement

Activities

Advancing Care

Information

2017 MIPS Scoring

Improvement Activities

Advancing Care Information

Note: These are default weights; the weights can be adjusted in certain circumstances and will change in future performance years

Quality

60%

Cost

0% 15% 25%

Clinicians and groups scored from 1 to 100

Each category contributes a percentage of total score

Today’s webinar covers how to earn these points!

MIPS Timeline

• Submit some data after

January 1, 2017

• Neutral or small

payment adjustment

Test Partial Year

• Report for 90-day

period after January 1,

2017

• Small positive payment

adjustment

MIPS Pick your Pace

Full Year

• Fully participate

starting January 1,

2017

• Modest positive

payment adjustment

Not participating in the Quality Payment Program for the Transition Year will resultin a negative 4% paymentadjustment.

MIPS Submission Methods

Individual Group

Quality QCDR (Qualified Clinical

Data Registry) Qualified Registry EHR Claims

QCDR (Qualified Clinical Data Registry) Qualified Registry EHR Administrative Claims CMS Web Interface

(groups of 25 ormore)

CAHPS for MIPS Survey

Advancing Care Information

Attestation QCDR Qualified Registry EHR

Attestation QCDR Qualified Registry EHR CMS Web Interface

(groups of 25 ormore)

Improvement

Activities Attestation QCDR Qualified Registry EHR

Attestation QCDR Qualified Registry EHR

Quality Performance Category

Quality Concepts

Promotes measurement and improvement of care

processes, outcomes, patient experience, patient safety,

efficiency and care coordination

Ends and replaces the Physician Quality Reporting System (PQRS) and the Quality component of the Value-Based Payment Modifier (VM)

Greater flexibility in choosing measures that fit your practice

Variation in available measures, reporting requirements and scoring depending on submission method

Quality Measures

Quality category has 271 available measures*

CMS has created 30 specialty measure sets to help clinicians identify appropriate measures

Participants report at least 6 measures, including one “outcome” or “high priority” measure (reporting all measures from a measure set with <6 is also acceptable)

Measures available depend on submission method

Must submit all measures through same method CAHPS Survey measure is exception if selected as one of 6 All-cause hospital readmissions measure is automatically

calculated/scored for groups of 16+ with at least 200 cases

* Refer to https://qpp.cms.gov/mips/quality-measures for full list of measures, which can be filtered based on high-priority, submission method and specialty measure set

Measures by Method

Submission Method

Available For MeasuresAvailable

Measures Required

Reporting Period

Claims Individuals only 74 6+ 90 days

QCDR/Qualified Registry

Individuals and Groups

243 6+ 90 days

EHR Individuals and Groups

53 6+ 90 days

CMS Web Interface

Groups 25+ only

14 14 Full calendar year

CAHPS Survey Groups only 1 1 Full calendar year

Measure Benchmarks

• Claims, registry, EHR benchmarks are based on 2015 PQRS

• CAHPS benchmarks based on 2015 PQRS or CAHPS for ACO

• CMS Web Interface benchmarks based on shared-savings program

• Re-admissions has no benchmark in 2017

• All reporters (individuals and groups regardless of specialty or practice size) are combined into one benchmarkfor the submission method

• Benchmarks will be updated each MIPS performance year

Benchmarks only established for measures reported by 20 individuals/groups that also:

• Meet or exceed minimum case volume

• Meet or exceed data completeness criteria

• Have performancegreater than 0 percent

* Download complete quality benchmark data at https://qpp.cms.gov/docs/QPP_Quality_Benchmarks_Overview.zip

Measure Scoring

If a measure can be reliably scoredagainst a benchmark, then cliniciancan receive up to 10points

• Reliably scored means the following:• Benchmark exists• Sufficient case volume (>=20

cases for most measures; >=200 cases for readmissions)

• Data completeness met (report at least 50% of eligible patients)

• “Topped out” measures require 100% performance to earn 10 points

If a measure cannot be reliably scored against a benchmark, then clinician receives 3 points

• Benchmark doesn’t exist (may wish to avoid selecting these)

• Sufficient case volume failed (report data over longer period to avoid this)

• Data completeness criteria failed (report on all patients for whom measure applies to avoid this)

CMS will attempt to score each measure submitted against benchmarks. If reporting more than 6 measures, CMS will assign the ones that earn the most points.

Points by Benchmark

Measure benchmarks are divided into deciles

Measure performance in range of decile 3 earns between 3 and 3.9 points, in range of decile 4 earns between 4 and 4.9 points, etc.

“Topped out” measures may skip deciles

Measures will have different deciles/scoring for each submission method

* The above image is a real sample from https://qpp.cms.gov/docs/QPP_Quality_Benchmarks_Overview.zip

Points by Benchmark

Clinicians can receive up to 10% of maximum points for each of the following:

Submitting an additional high-priority measure

2 bonus points for each additional outcome and patient experience measure

1 bonus point for each additional high-priority measure

Using CEHRT to submit measures to registries or CMS

1 bonus point foreach measure submittedelectronically "end-to-end"

Bonus Points

Clinicians can receive a maximum number of points depending on submission method:

Claims, Registry, EHR

• 10 points max for 6 measures + 1 readmission measure

• if readmission measure does not apply

70POINTS

60POINTS

Maximum Points

CMS Web Interface

• for groups with complete reporting(14 measures) and readmissionsmeasure

• for groups with complete reporting(14 measures) and no readmissions measure

120POINTS

110POINTS

* Only 11 of 14 measures have a benchmark. The 3 measures that don’t will not be scored if you report all the measures, but you would be penalized for not reporting all the measures

Points earned on required quality

measures=

Maximum number

of points

Total Quality Performance

Category Score

Note: Maximum score cannot exceed 100%; a score of 100% or greater will result in full 60 points for the Quality performance category of MIPS total score (85 points if ACI is re-weighted)

Any bonus points

+

Total Quality Score

Quality Scoring Examples

Scoring Example A

Measure Performance Benchmark Decile (Range) Points

Diabetes: Medical Attention for Nephropathy

80.3% 5 (79.17 - 83.01) ~5.1

Diabetes: Eye Exam 93.5% 4 (89.69 - 95.95) ~4.5

Diabetes: Foot Exam 40.1% 6 (39.81 - 55.87) ~6

Hypertension: Controlling BP* 72.2% 9 (71.93 - 75.11) ~9

Falls: Risk Assessment* 99.8% 7 (84.17 - 99.82) ~7.9

Falls: Plan of Care* 99% 9 (98.08 - 99.99) ~9.5

Group of 3 clinicians reporting minimum 6 measures for 90-day period using registry submission method

* High-priority measure

Scoring Example A

Points earned on required measures = 42 (estimated)

Bonus points = 2 (two additional high-priority measures x 1 point each, no electronic “end-to-end” reporting)

Maximum points = 60 (not eligible for readmissions measure)

(Total + Bonus) / Maximum = 44/60, 73.33%

73.33% * maximum 60 points for Quality performance category = 44

ECs in this group earn 44 points in the Quality category towards

total MIPS score

Scoring Example B

Measure Performance Benchmark Decile (Range) Points

Diabetes: Hemoglobin A1c Poor Control* 11.5% 7 (14.14 – 9.10) ~7.5

Diabetes: LDL-C Control* 70% 10 (>=69.36) 10

Breast Cancer Screening 51.5% 7 (47.92 - 55.25) ~7.5

Hypertension: Improvement in BP* 28% 9 (27.62 – 39.04) ~9

Colorectal Cancer Screening** 33.5% 6 (33.46 – 44.39) ~6

Cervical Cancer Screening 50% 8 (45.00 – 54.77) ~8.5

Anti-depressant Medication Management 85% 10 (>=80.63) 10

All-cause hospital readmissions*** 75% TBD 9

Group of 20 clinicians reporting 8 measures for a 365-day period using EHR submission method

1 clinician is a hospitalist and elects to re-weight ACI (25 pts) to Quality

* Outcome measure

** Measure thrown out because there are 6 submitted measures with higher scores

*** Included automatically (no submission) as a 7th measure

Scoring Example B

Points earned on required measures = 61.5 (estimated)

Bonus points = 10 (two additional outcome measures x 2 points each, six submitted using electronic “end-to-end” reporting x 1 point each)

Maximum points = 70 (eligible for readmissions measure)

(Total + Bonus) / Maximum = 71.5/70, 102.1%

102.1% * maximum 60 points for Quality performance category = 60

ECs in this group earn full 60points in the Quality category

towards total MIPS score

Hospitalist EC earns full 85 points

Scoring Example C

Measure Performance Benchmark Decile (Range) Points

Pneumonia Vaccination Status for Older Adults*

62% 5 (61.68 – 70.47) 3

Pain Assessment and Follow-Up* 93.5% 4 (89.69 - 95.95) 3

Advance Care Plan* 70% 5 (62.87 – 86.91) 3

Individual clinician reporting 3 measures for less than 90-day period using claims submission method

* Not enough data submitted for scoring against benchmarks, maximum 3 points allowed (no bonus points available)

Scoring Example C

Points earned on required measures = 9

Bonus points = 0 (none allowed when reporting <90 days)

Maximum points = 60 (not eligible for readmissions measure)

(Total + Bonus) / Maximum = 9/60, 15%

15% * maximum 60 points for Quality performance category = 9

EC earns 9 points in the Quality category towards total MIPS

score

Quality Reporting Considerations and

Resources

• Submit a minimum of 1

patient in numerator of

1 quality measure

• Earn minimum 3 points, ensure avoidance of MIPS negative adjustment

Test Partial Year

• Report measures for

minimum 90 days

• Earn points based on

number of measures

submitted and

reliably scored against

benchmarks

Quality Pick your Pace

Full Year

• Report measures

for entire year

• Earn points based on

number of measures

submitted and

reliably scored

against benchmarks

Not reporting anything will result in 0 points for the Quality category towards your overall MIPS score

Claims Reporting

Only available for individual reporting

Requires coding of Medicare claim forms* Denominator criteria based on demographics,

diagnoses, procedure codes (usually CPT/HCPCS) Numerator usually based on CPTII codes with “cost” of

$0.00 or $0.01 Exclusion usually based on modifier codes

Measure scores determined from analysis of claims; does not require submission of any additional information

Data completeness criteria = 50% of eligible patient population for each measure (Medicare patients only)

* Download measure coding specifications at https://qpp.cms.gov/docs/QPP_quality_measure_specifications.zip

EHR Reporting

Only available if using 2014 or 2015 CEHRT

Limited to reporting measures supported by your CEHRT

Requires careful adherence to documentation workflows Request quality measure guides from vendor Train staff on documentation best practices Run quality reports often to check for accuracy

Measure scores submitted directly to CMS by CEHRT vendor, on behalf of clinicians

Data completeness criteria = 50% of eligible patient population for each measure (all payers)

Registry Reporting

Qualified registry/QCDR are CMS-approved entities that collect and submit data on behalf of MIPS participants

Typically designed with more robust analytics than EHR

QCDR are different from qualified registry because it is not limited to measures within MIPS (can develop and submit new measures for CMS approval)

Registries may offer to submit for Advancing Care Information and Improvement Activities as well

Data completeness criteria = 50% of eligible patient population for each measure (all payers)

* View list of qualified registries at https://qpp.cms.gov/docs/QPP_2017_Qualified_Registries.pdf

* View list of QCDR at https://qpp.cms.gov/docs/QPP_2017_CMS_Approved_QCDRs.pdf

Web Interface Reporting

Formerly known as the GPRO Web Interface

Secure internet-based submission for groups of 25 or more MIPS clinicians reporting to CMS

Pre-populated with claims data from Medicare beneficiaries assigned to the group

Eliminates need to search for and select measures (required to report all 15)

Requires registration by June 30 (too late this year!)

Data completeness criteria = meet CMS patient sampling requirements (Medicare patients only)

* Read about CMS Web Interface at https://qpp.cms.gov/docs/QPP_CMS_Web_Interface_Fact_Sheet.pdf

Resources

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-

Assessment-Instruments/Value-Based-Programs/MACRA-

MIPS-and-APMs/QPP-MIPS-Quality-and-Cost-Slides.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-

Assessment-Instruments/Value-Based-Programs/MACRA-

MIPS-and-APMs/MIPS-Scoring-Methodology-slide-deck.pdf

https://www.qualityinsights-

qin.org/getattachment/Events/Archived-Events/MIPS-

Quality-webinar_FINAL_4-19-17_508.pdf.aspx

Quality Payment Program of Illinois

http://qpp-il.org

Program Info: info@qpp-il.org

QPP Questions: qpphelp@chitrec.org

OR

844-QPP-DESK (844-777-3375)