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How Are You Scoring on Your Quality Measures?
Learning Forum Fridays
Countdown to MIPS Data Submission Webinar Series
Jason WestHealth Informatics Specialist II
Health Services Advisory Group (HSAG)September 8, 2017
Disclosure
I have nothing to report, nor are there any real or perceived conflicts of interest, implied or expressed, in the following presentation.
Jason West, Health Informatics Specialist II
2
Agenda
• Overview of MIPS reporting
• Quality category
• What are the Quality measures
• Data reporting methodologies
• Pick your pace
• How are your Quality scores calculated?
• How to maximize Quality scores?
• Program resources
3MIPS = Merit-based Incentive Payment System
Overview of MIPS ReportingWhat Do I Need To Know?
MIPS Visualization
A visualization of how legacy programs streamline into the MIPS performance categories
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PQRS Quality
VM Cost
EHR Advancing Care
Information
Example of legacy program phase out for PQRS
Last Performance Period
2016
PQRS Payment End
2018
Source: The Centers for Medicare & Medicaid Services PQRS = Physician Quality Reporting SystemVM = Value-Based Payment ModifierEHR= Electronic Health Record
What Are the Performance Category Weights?
• Weights assigned to each category is based on a 1 to 100 point scale.
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Transition Year Weights
Quality Cost Improvement
Activities
Advancing Care
Information
60% 0% 15% 25%
Note: These are defaults weights; the weights can be adjusted in certain circumstances.
When Does MIPS Officially Begin?
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Performance year
Submit Feedback available Adjustment
2017Performance Year
• Performance period opens January 1, 2017.
• Performance period closes December 31, 2017.
• Clinicians care for patients and record data during the year.
March 31, 2018Data Submission
• Deadline for submitting data is March 31, 2018.
• Clinicians are encouraged to submit data early.
Feedback
• CMS provides performance feedback after data is submitted.
• Clinicians will receive feedback before the start of the payment year.
January 1, 2019Payment Adjustment
• MIPS payment adjustments are prospectively applied to each claim beginning on January 1, 2019.
Source: The Centers for Medicare & Medicaid Services
MIPS QualityImpact on MIPS Scoring
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MIPS Scoring for Quality (60 Percent of Final Score in Transition Year)
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Select 6 of the approximately 300 available quality measures (minimum of 90 days)• Or a specialty set• Or CMS Web Interface measures
Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks.
Failure to submit performance data for a measure = 0 points.
Quick Tip:Easier for a clinician who participates longer to meet case volume criteria needed to receive more than 3 points.
Bonus points are available
• 2 points for submitting
an additional
outcome measure
• 1 point for submitting
an additional
high-priority measure
• 1 point for using CEHRT to
submit measures
electronically end-to-end
Source: The Centers for Medicare & Medicaid Services
MIPS Performance Category: Quality
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60%
60% of the final score
Select 6 of about 271 quality measures(minimum of 90 days to be eligible for maximum payment adjustment); 1 must be:• Outcome measure; OR• High-priority measure—defined as outcome
measure, appropriate use measure, patient experience, patient safety, efficiency measures, or care coordination.
Different requirements for groups participating via CMS Web Interface or those in MIPS Alternative Payment Models (APMs)
May also select specialty-specific set of measures
The all-cause hospital readmission measure will be scored for groups that have ≥ 16 clinicians and a sufficient number of cases (no requirement to submit).
CMS = The Centers for Medicare & Medicaid Services
Source: The Centers for Medicare & Medicaid Services
MIPS Performance Category: Quality—Requirements for the Transition Year
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• Requirements for the Transition Year:
Submit Something
• Test Means…— Submitting a minimum amount of data for one measure for 2017
Submit a Partial Year Submit a Full Year
+%
• Partial and Full Means…— Submitting at least six quality measures, including at least one Outcome measure, for 90 days or a full year.
• Quality measures vary by submission mechanism.
Note: Groups are encouraged to select the quality measures that are most appropriate for their practice and patient population.
Source: The Centers for Medicare & Medicaid Services
Data Reporting MethodologiesPick the Method Best for Your Practice
Choose a Submission Method and Verify Its Capabilities
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How do I do this?• Choose a data submission option.
– For Qualified Registries, QCDRs, and CAHPS® for MIPS Survey:• Check that each of the submission options are approved by CMS.
– For EHR reporting:• Check that your EHR is certified by the Office of the National Coordinator for Health
Information Technology.
– For Claim reporting:• Verify with your biller any codes required for Quality Measure reporting.
• Review the available submission options for 2017— Speak with your specialty society about your options.
— Consider using a Technical Assistance program (TCPI, QIN-QIOs, QPP-SURS) for decision support.
Visit qpp.cms.gov for information on submission options.
QCDR = Qualified Clinical Data RegistriesCAHPS® = Consumer Assessment of Healthcare Providers and SystemsTCPI = Transforming Clinical Practice Initiative;QPP-SURS = Quality Payment Program-Small, Underserved, & Rural Support
Source: The Centers for Medicare & Medicaid Services
Submit Your Data Early
How do I do this?• Care for your patients and record the data.• Submit your data to CMS prior to the March 2018
deadline using your chosen submission method.– CMS anticipates the data submission window to open
January 1, 2018.– Claims reporting must start now to have adequate data for
the reporting year.– You are encouraged to submit as early as possible
following this date to ensure the timely receipt and accuracy of your data.
15 Source: The Centers for Medicare & Medicaid Services
Pick Your PaceWhat Is Best for Your Practice?
Pick Your Pace for Participation for the Transition Year
Participate in an Advanced APM
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+%
MIPS
Test Pace Partial Year Full Year
• Some practices may choose to participate in an Advanced APMin 2017
Submit Something: • Submit some data
after January 1, 2017
• Neutral or small payment adjustment
Submit a Partial Year: • Report for 90-day
period after January 1, 2017
• Some positive payment adjustment
Submit a Full Year: • Fully participate
starting January 2017
• Modest positive payment adjustment
Not participating in the QPP for the Transition Year will result in a negative 4 percent payment adjustment.
Source: The Centers for Medicare & Medicaid Services
MIPS: Choosing to Test for 2017
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Source: The Centers for Medicare & Medicaid Services
1 Quality Measure
Submit Something
• Submit a minimum of 2017 data to Medicare• Avoid a downward adjustment
Minimum Amount of Data
1 Improvement Activity
4 or 5* RequiredAdvancing Care
Information Measures
OR OR
* Depending on certified electronic health record technology (CEHRT) edition
You have asked: What is a minimum amount of data?”
MIPS: Partial Participation for 2017
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• Submit 90 days of 2017 data to Medicare• May earn a positive payment adjustment
Submit a Partial Year
“So what?”—If you are not ready on January 1, you can start anytime between January 1 and October 2.
Need to send performance data by March 31, 2018
Source: The Centers for Medicare & Medicaid Services
MIPS: Full Participation for 2017
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• Submit a full year of 2017 data to Medicare• May earn a positive payment adjustment• Best way to earn largest payment adjustment is to
submit data on all MIPS performance categories
+%
Submit a Full Year Key takeaway: Positive adjustments are based on the performance data on the performance information submitted, not the amount of information or length of time submitted.
Source: The Centers for Medicare & Medicaid Services
MIPS Quality Measures SelectionSelect Measures to Maximize Your Score
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QPP Quality Website
22 Source: The Centers for Medicare & Medicaid Services
Selecting Quality Measures
Choose From:
• 74 Claims measures
• 53 EHR measures
• 243 Registry measures
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Select Measures by Specialty
24 Source: The Centers for Medicare & Medicaid Services
Sample MIPS MeasuresHow They are Ranked and Scored
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Sample QPP Quality Measure
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Measure NamePreventive Care and Screening: Tobacco Use:
Screening and Cessation Intervention
Measure ID 226 226 226Submission Method Claims EHR Registry/QCDR
Measure Type Process Process ProcessBenchmark Y Y Y
Decile 3 95.60 - 97.85 72.59 - 81.59 76.67 - 85.53Decile 4 97.86 - 99.25 81.60 - 86.68 85.54 - 89.87Decile 5 99.26 - 99.99 86.69 - 90.15 89.88 - 92.85Decile 6 -- 90.16 - 92.64 92.86 - 95.14Decile 7 -- 92.65 - 94.67 95.15 - 97.21Decile 8 -- 94.68 - 96.58 97.22 - 99.10Decile 9 -- 96.59 - 98.51 99.11 - 99.99
Decile 10 100 >= 98.52 100Topped Out Yes No No
Source: The Centers for Medicare & Medicaid Services
Sample QPP Inverse Quality Measure
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Measure Name Diabetes: Hemoglobin A1c Poor Control
Measure ID 1 1 1Submission Method Claims EHR Registry/QCDR
Measure Type Outcome Outcome OutcomeBenchmark Y Y Y
Decile 3 35.00 - 25.72 54.67 - 35.91 83.10 - 68.19Decile 4 25.71 - 20.32 35.90 - 25.63 68.18 - 53.14Decile 5 20.31 - 16.23 25.62 - 19.34 53.13 - 40.66Decile 6 16.22 - 13.05 19.33 - 14.15 40.65 - 30.20Decile 7 13.04 - 10.01 14.14 - 9.10 30.19 - 22.74Decile 8 10.00 - 7.42 9.09 - 3.34 22.73 - 16.82Decile 9 7.41 - 4.01 3.33 - 0.01 16.81 - 10.33
Decile 10 <= 4.00 0 <= 10.32Topped Out No No No
Source: The Centers for Medicare & Medicaid Services
Program Resources
Program Resources (cont.)
• CMS QPP website
– https://qpp.cms.gov/mips/quality-measures
• HSAG QPP Service Center website
– https: www.hsag.com/QPP
Questions
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Thank you!
Jason West, BS, M+CSM
HSAG Health Informatics Specialist II
(818) 265-4654| [email protected]
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, 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. Publication No. QN-11SOW-D.1-08292017-01
