MIPS, Scoring and Submission Methods

David H. Smith, MBAHIT Project Manager

HealthInsight

Our business is redesigning health care systems for the better

HealthInsight is a private, non-profit, community based organization dedicated to improving health and health care in the

western United States.

www.healthinsight.org | Twitter: @HealthInsight_

Mountain-Pacific Quality Health

We are the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for• Montana• Wyoming• Hawaii• Alaska

• Guam• American Samoa• The Commonwealth of the

Northern Mariana Islands

Today’s Presentation

• Scoring–MIPS

• Quality• ACI• Improvement

Activities• Costs - forthcoming

• Submission–Solo–Group–Strategies for

selection–Timelines

Scoring

• Quality 60 percent• Advancing Care Information 25 percent• Improvement Activities 15 percent• Costs (0 percent of score, not required this year

2017) –Quick review on what we think is coming

The MIPS Pie

Quality 60%Advancing Care

Information 25%

Improvement Activities 15%

2017

The MIPS Pie

Quality 50%

Advancing Care Information 25%

Improvement Activities

15%

Cost 10%2018

The MIPS Pie

Quality 30%

Advancing Care Information 25%

Improvement Activities

15%

Cost 30%

2019

Sample

Category TotalPossible

Limit Actual Percent Weight Score

Quality Multiplemethods –fraction – extra points

100% 50 50% 60 30

ACI 155/100 100% 115 100% 25 25IA 40/40 or

20/20100% 20/40 50% 15 7.5

Costs 0/0

Total 62.5

MIPS – Quality Scoring

• Quality Scoring based on benchmarks, set up with deciles

• Three points for submitting each measure, up to 10/measure if in 10th decile

• See benchmarks document• Extra point for outcome/high priority

measures, in addition to six measures • Include at least one outcome measure

Deciles

Deciles – what they aren’t and what they are:• The decile could be anywhere on the spectrum

from x+0% to x-100 percent• A quality measure reporting at 45 percent is

not necessarily in the fourth decile• 45 percent could be in the third decile or the

eighth decile depending on the performance of others

Examples of Scoring Quality in MIPS

• Within 3rd decile: 3+ points toward MIPS quality• Within 1st decile: 3+ points toward MIPS quality• Within 4th decile: 4+ points toward MIPS quality• Within 5th decile: 5+ points toward MIPS quality• Within 8th decile: 8+ points toward MIPS quality• Within 2th decile: 3+ points toward MIPS quality

Example: Poor Control of A1C

Measure_NameMeasure

_IDSubmission_

MethodMeasure_

TypeBenchm

ark Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9Decile

10Topped

Out

Diabetes: Hemoglobin A1c Poor Control 1 Claims Outcome Y35.00 -25.72

25.71 -20.32

20.31 -16.23

16.22 -13.05

13.04 -10.01

10.00 -7.42

7.41 -4.01

<= 4.00 No

Diabetes: Hemoglobin A1c Poor Control 1 EHR Outcome Y54.67 -35.91

35.90 -25.63

25.62 -19.34

19.33 -14.15

14.14 -9.10

9.09 -3.34

3.33 -0.01 0 No

Diabetes: Hemoglobin A1c Poor Control 1Registry/QCD

R Outcome Y83.10 -68.19

68.18 -53.14

53.13 -40.66

40.65 -30.20

30.19 -22.74

22.73 -16.82

16.81 -10.33

<= 10.32 No

Decile 3

Decile 4

Decile 5

Decile 6

Decile 7

Decile 8

Decile 9

Decile 10

Topped Out

Claims 35.00 - 25.72

25.71 - 20.32

20.31 - 16.23

16.22 - 13.05

13.04 - 10.01

10.00 - 7.42

7.41 - 4.01

<= 4.00

No

EHR 54.67 - 35.91

35.90 - 25.63

25.62 - 19.34

19.33 - 14.15

14.14 - 9.10

9.09 - 3.34

3.33 - 0.01

0 No

Registry/QCDR 83.10 - 68.19

68.18 - 53.14

53.13 - 40.66

40.65 - 30.20

30.19 - 22.74

22.73 - 16.82

16.81 - 10.33

<= 10.32

No

1. Using Claims submitted method, how many points for 15%?

2. Using EHR method, how many points for 20%?3. Using Registry method, how many points for

15%?

Quality Scoring Scenarios

• Solo – It Depends…– Most submit six or more measures. (Claims, EHR, QCDR, QR,

Attestation) for full consideration of measures/support– Many claims based measures are topped out– Suggest evaluating benchmarks.– Consider custom QCDRs if clinically relevant, ideally, more than 20

providers submitting measures so benchmarks can be set. Also, consider where those benchmarks may be for performance reasons.

– Not all measures in each Specialty Measure Set will be applicable to all clinicians in a given specialty. If the set includes less than six applicable measures, the eligible clinician should only report the measures that are applicable.

Note Specialty Measure Sets

Note One of the Specialties w/< 6 Measures.

Equation for Scoring Quality (60% towards MIPS)

• If you’re in traditional MIPS, quality counts towards 60 percent of your total score. (lower in AAPMs where costs may also count)

Scoring Advancing Care Information

• Three components• Core • Performance• Bonus

MIPS Category: Advancing Care Information (ACI)

• 25 percent of Final Score in 2017• Promotes patient engagement and the electronic

exchange of information using certified EHR technology• Replaces the Medicare EHR Incentive Program (a.k.a.

Meaningful Use)• Greater flexibility in choosing measures• In 2017, there are two measure sets for reporting:

– ACI for those using 2015 edition CEHRT – 2017 Transition for 2014 edition CEHRT

MIPS Category: Points Possible

• Maximum Possible 155 Points. 100 will get you to the full 25 points as part of the total score for MIPS. – Base Score – 50 points– Performance – 90 points– Bonus – 15 pointsChoose to submit up to nine measures for a minimum of 90 days for additional credit.

• Bonus Credit for Public Health and Clinical Data Registry Reporting Measures

Base – 50 Points

Perform each of these with a yes/no or at least one in the numerator to demonstrate participation.

Any year 2014 or 2015 Certified Product 2017 version or for 2014 cert product users

Security Risk Analysis Security Risk Analysis

ePrescribing ePrescribing

Provide Patient Access (+ Performance) Provide Patient Access (+ Performance)

Send Summary of Care (+ Performance) Health Information Exchange (+ Performance)

Request/Accept Summary of Care Record (+ Performance)

Performance – 90 Points

Any Year 2014/2015 Certified Products 2017 – if on 2014 certified product only

Provide Patient Access 10 pts Provide Patient Access 20 pts

Send a Summary of Care 10 pts Health Information Exchange 20 pts

Request/Accept Summary of Care 10 pts View, Download, Transmit 10 pts

Patient Specific Education 10 pts Patient Specific Education 10 pts

View Download Transmit 10 pts Secure Messaging 10 points

Secure Messaging 10 pts Medication Reconciliation 10 pts

Patient Generated Health Data 10 pts Immunization registry 0 or 10 points

Clinical Information Reconciliation 10 pts

Immunization registry reporting 0 or 10 pts

Bonus – 15 Pts

Requirements for Bonus Score Requirements for Bonus Score

(report to 1 or more of the public health and clinical data registries) 5 points

(report to 1 or more of the public health and clinical data registries) 5 points

Syndromic Surveillance Registry Reporting Syndromic Surveillance Registry Reporting

Electronic Case Reporting Specialized Registry Reporting

Public Health Registry Reporting Clinical Data Registry Reporting

10 points options below 10 points options below

Report certain improvement activities Report certain improvement activities

Advancing Care Information Calculator.xlsx

Improvement Activity Scoring

• 40 Points for groups > 15 providers• 20 Points required for groups < 15 providers

• High 20 Points• Medium 10 Points

Scenarios

• Larger groups will typically have several improvement activities happening in their system.

• Finding improvement activities that are supported by 1+ providers give credit to the whole group

Full Support for Improvement Activities

• Patient Centered Medical Home (PCMH)• State-based PCMH (if approved like Oregon’s

PCPCH)

Sample

Category TotalPossible

Limit Actual Percent Weight Score

Quality Multiplemethods –fraction – extra points

100% 50 50% 60 30

ACI 155/100 100% 115 100% 25 25IA 40/40 or

20/20100% 20/40 50% 15 7.5

Costs 0/0

Total 62.5

Submission Methods

NEXT TOPIC – Submission Methods• Group and Solo submission options• Your TIN may be choosing a method for you• If working in multiple TINs, or if you have your own

clinic aside from employment, you may need to report for each TIN

• Providers moving from other TINs may utilize reporting from other domains

Submission Methods

EHR QualifiedRegistry

QCDR Attestation

WebInterface(June 30 –groups only)

CAHPS(June 30 groups only, counts as 1)

Claims

Quality X X X X X X

Advancing Care Info.

X X X X X

ImprovementActivities

X X X X X

Costs X

Group Providers

• CMS Web Interface (only available to groups with 25 or more eligible clinicians)

• Qualified Clinical Data Registry (QCDR)• Qualified Registry• Electronic Health Record (EHR)• CAHPS for MIPS Survey (only available to groups with

2 or more eligible clinicians)• Attestation – ACI and IA only (not quality)

Submission Methods

EHR QualifiedRegistry

QCDR Attestation

WebInterface(June 30)

CAHPS(June 30 groups only)

Claims

Quality X X X X X X

Advancing Care Info.

X X X X X

ImprovementActivities

X X X X X

Costs X

Strategies for Selection

• You can only use one submission method per category in 2017

• Possibly changing to multiple methods per category in future years per 11 days old proposed rule on 2018 MIPS

Timelines

• June 30, three days from now• Deadline for Web Interface• Deadline for CAHPS

QCDR

Quality ACI Improvement Activity

If using custom or registry measures, confirm that enough providers will report

Confirm your chosen QCDR/ssupport this, or arrange for optional method of submission.

Confirm your chosen QCDR/ssupport this, or arrange for optional method of submission.

Confirm that benchmarks are or will be available.Evaluate value of submitting more measures to your organization and to your specialty area.

https://qpp.cms.gov/docs/QPP_2017_CMS_Approved_QCDRs.pdf

QCDR Suggestions

• Measures submitted may not be “official” MIPS measures but can count.

• Suggestions:– Consider appropriateness to your specialty– You may get a score higher than 3 for your performance

within deciled averages if others submit (over 20), suggest confirming with vendor

– Suggest confirming average reporting rates will be available

Qualified Registry – Solo

https://qpp.cms.gov/docs/QPP_MIPS_2017_Qualified_Registries.pdf

Quality ACI Improvement ActivityIf using custom or registry measures, confirm that enough providers will report

Confirm your chosen QR/ssupport this, or arrange for optional method of submission.

Confirm your chosen QR/ssupport this, or arrange for optional method of submission.

Confirm that benchmarks are or will be available.Evaluate value of submitting more measures to your organization and to your specialty area.

Qualified Registry Suggestions

• Measures are on the list w/information regarding benchmarks

• Consider if benchmarks exist• Consider using measures that support state-based

initiatives if you are in primary care for 2/1 reporting benefit– Example: SBIRT, or alcohol and substance abuse measures

have applicability to state based reports in places like Oregon

Electronic Health Record

• Advantages of using EHR vendor to submit– EHR real time knowledge of where your measures are at, possibly

daily, or at least monthly or quarterly in most cases– Up to date information

• Some vendors may share in mutual benefits of improving quality

• Consider measures submission benefits to performance rankings in benchmarks. Some methods of submission are easier to achieve

Quality ACI Improvement ActivityEvaluate measures Obvious benefits to utilizing

ACI for EHR submission. Improvement Activities may be more difficult to prove, confirm.

Administrative Claims

Quality ACI Improvement ActivityClaims data can be difficult to confirm for many quality measures, and more difficult to compete in with standard measures.

Not applicable. N/A

Attestation

Quality ACI Improvement ActivityN/A Consider probability of

errorConsider data validation to support improvement activities if audited

Helpful if one more than one EHR

Web Interface

Quality ACI Improvement Activity15 measures Vendor submission

optionsAbility to support improvement activities using this method.

Upcoming Webinar Series

•Improving Your ScoreJuly 11

All sessions will be held at 1-2 p.m. MTRegister at www.healthinsight.org/qpp

Questions

This material was prepared by HealthInsight, the Medicare Quality Innovation Network-Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-D1-17-40

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Visit us online at www.mpqhf.org.

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