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

Source: https://qpp.cms.gov/about/resource-library

Source: https://qpp.cms.gov/about/resource-library

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”

Nu

mb

er o

f E

pis

od

es o

f C

are

low avg high

QUALITY

ALL do better-not just

“bad apples”

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

0

20

40

60

80

100Se

p-04

Oct

-04

Nov

-04

Dec

-04

Jan-

05Fe

b-05

Mar

-05

Apr-

05M

ay-0

5Ju

n-05

Jul-0

5Au

g-05

Sep-

05O

ct-0

5N

ov-0

5D

ec-0

5Ja

n-06

Feb-

06M

ar-0

6Ap

r-06

May

-06

Jun-

06Ju

l-06

Aug-

06Se

p-06

Oct

-06

Nov

-06

Dec

-06

Jan-

07Fe

b-07

Mar

-07

Apr-

07M

ay-0

7Ju

n-07

Jul-0

7Au

g-07

Sep-

07O

ct-0

7N

ov-0

7

% T

ota

l C

ho

leste

rol

Teste

d Start Automated

StopAutomated

StopAutomated

Re-Start Automated

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

qpp@scorh.net

http://www.scorh.nethttp://twitter.com/scruralhealthhttp://www.facebook.com/SCORHhttp://www.youtube.com/user/scruralhealth