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MIPS Improvement Activities:
Building Blocks for Value and Quality Care
Agenda
▪ Basics of MIPS
▪ MIPS 2017
▪ The MIPS-Medicaid MU relationship
▪ Improvement activities as building blocks
▪ Improvement Activity Examples
▪ Utilizing CMH strengths
The Future of Medicare Value-Based Payment Reform
APMs-Advanced Alternative Payment Models
▪ Medicare Shared Savings Program ACOs-Track 2
▪ Medicare Shared Savings Program ACOs-Track 3
▪ Next Generation ACO Model
▪ Comprehensive ESRD Care Model
▪ Oncology Care Model OCM
▪ CPC+
Be exempt from MIPS reporting
Earn 5% Medicare incentive payment
CMS expanding eligible APMs for 2018
Why MIPS?
Payment:
You may earn a
positive MIPS
payment adjustment
for 2019 if you
submit 2017 data by
March 31, 2018
Performance:
The first performance
period opens January
1, 2017 and closes
December 31, 2017.
During 2017, record
quality data and how
you used technology to
support your practice
Send in performance
data:
To potentially earn a
positive payment
adjustment under
MIPS, send in data
about the care you
provided and how your
practice used
technology in 2017 to
MIPS by the deadline,
March 31, 2018.
Feedback:
Medicare gives
you feedback
about your
performance
after you send
your data.
Payment Adjustments
CMS always uses a 2 year look-back method
What that means for CMHs?
Physician PhysicianAssistant
NursePractitioner
Clinical NurseSpecialist
Certified
Registered NurseAnesthetist
Who is Eligible?
• Payment adjustments likely to be minor until 2021• Social workers and psychologists likely to become eligible
clinicians in program year 2019
Individual vs. Group Reporting
If clinicians participate as a group, they are assessed as group across all 4 MIPS performance categories
Why does this matter?
Low-Volume Threshold
▪ Clinicians billing Medicare Part B up to $30,000 in allowed charges or providing care for less than 100 Part B patients in a year
▪ Low-volume threshold will be applied at individual clinical level (national provider identification (NPI)/tax identification number (TIN) for those reporting individually and group practice (TIN) level for group reporting.
▪ A clinician may qualify for exclusion at the individual level (NPI/TIN) but if clinician is part of a group that does not meet criteria, he will be required to participate in MIPS as a group
▪ Expect definition of Low-Volume Threshold to change for 2018
▪ Most likely will report ECs as individuals for 2017 and 2018
▪ Will want to consider reporting as a group in 2019
What that means for CMHs?
MIPS
▪ MIPS is complicated rule and everyone is still learning
▪ CMS will need to provide further guidance and clarification
▪ Takeaway-MIPS is doable in 2017 if:
– You are currently doing Meaningful Use
– You are currently doing PQRS
Starting Point-Assess What You Do (or Don’t Do Now)
▪ General
– Eligible Clinicians
– Motivation
– Practice Demographics
▪ Quality Measures
– PQRS Status
– Initial Selection of Possible Measures
– Types of Measures
– Planning
▪ Advancing Care Information
– MU Status
– CEHRT
– Obstacles
– Registry Participation
▪ Improvement Activities
– Initial Selection
▪ Cost
– Review status of current reports
MIPS Questionnaire
MIPS Categories
MIPS Score Components-2017-2019
Quality
▪ Replaces PQRS
Quality
▪ Report at least 6 quality measures
– Or report on a specialty measure set
▪ Must include 1 outcome measure
▪ For Group Reporting:
– Registration usually takes place from April-June of program year
– Groups using the web interface must report on 15 quality measures for a full year
Quality Scoring
▪ Each quality measure is assigned a possible 10 quality points based upon the percentile-basis performance of the measure relative to national peer benchmarks.
– If reporting six measures, 60 quality points available
▪ In addition to the six quality measures, CMS calculates either two (for individual clinicians and groups with less than 10 clinicians) or three (for groups with 10+ clinicians) population (claims-based) quality measures
– Additional 10 or 20 quality points available depending on number of clinicians in the group
Quality-Scoring
For example, if a single PQRS measure has a 62% measure rate that is better than 60% of peers reflected in the benchmark, then that measure would earn seven out of 10 possible points.
Benchmark DecileSample Quality Measure Benchmarks
Possible Points with 3-Point Floor
Possible Points Without 3-Point Floor
Benchmark Decile 1 0.0-9.5% 3.0 1.0-1.9
Benchmark Decile 2 9.6-15.7% 3.0 2.0-2.9
Benchmark Decile 3 15.8-22.9% 3.0-3.9 3.0-3.9
Benchmark Decile 4 23.0-35.9% 4.0-4.9 4.0-4.9
Benchmark Decile 5 36.0-40.9% 5.0-5.9 5.0-5.9
Benchmark Decile 6 41.0-61.9% 6.0-6.9 6.0-6.9
Benchmark Decile 7 62.0-68.9% 7.0-7.9 7.0-7.9
Benchmark Decile 8 69.0-78.9% 8.0-8.9 8.0-8.9
Benchmark Decile 9 79.0-84.9% 9.0-9.9 9.0-9.9
Benchmark Decile 10 85.0%-100% 10 10
Quality Scoring
▪ If all eight measures earned seven points each, then the total points would be 8 x 7 = 56 out of a possible 80 points, or a 56/80 = 70%.
▪ As the Quality category for the CY2017 performance year has a weight of 60%, then a quality score of 70% would result in the Quality category contributing 70% x 60% x 100 = 42 points to the clinician’s overall MIPS Final Score.
Quality Reporting Bonus Points
▪ MIPS also provides additional paths to achieve a quality score of 100% by granting bonus points for certain quality reporting activities.
– Up to 10% for submitting high priority measures
– Up to 10% for end-to-end electronic reporting
▪ Total bonus points are capped at 10% of the denominator of the quality score
Cost
▪ No reporting requirement
▪ Clinicians assessed on Medicare claims data
▪ Based on episodic costs
▪ 0% of final score in 2017
▪ CMS will still provide feedback on how you performed in this category in 2017, but it will not affect your 2019 payments.
Cost-Example of Episode Cost Measure Group
Major Depressive Disorder F32 Major Depressive Disorder, Single Episode Major Depressive Disorder F320 Major Depressive Disorder, Single Episode, Mild Major Depressive Disorder F321 Major Depressive Disorder, Single Episode, Moderate Major Depressive Disorder F322 Major Depressive Disorder, Single Episode, Severe Without Psychotic Features Major Depressive Disorder F323 Major Depressive Disorder, Single Episode, Severe With Psychotic Features Major Depressive Disorder F324 Major Depressive Disorder, Single Episode, In Partial Remission Major Depressive Disorder F325 Major Depressive Disorder, Single Episode, In Full Remission Major Depressive Disorder F329 Major Depressive Disorder, Single Episode, Unspecified Major Depressive Disorder F33 Major Depressive Disorder, Recurrent Major Depressive Disorder F330 Major Depressive Disorder, Recurrent, Mild Major Depressive Disorder F331 Major Depressive Disorder, Recurrent, Moderate Major Depressive Disorder F332 Major Depressive Disorder, Recurrent Severe Without Psychotic Features Major Depressive Disorder F333 Major Depressive Disorder, Recurrent, Severe With Psychotic Symptoms Major Depressive Disorder F334 Major Depressive Disorder, Recurrent, In Remission Major Depressive Disorder F3340 Major Depressive Disorder, Recurrent, In Remission, Unspecified
Major Depressive Disorder F3341 Major Depressive Disorder, Recurrent, In Partial Remission
Major Depressive Disorder F3342 Major Depressive Disorder, Recurrent, In Full Remission
Major Depressive Disorder F339 Major Depressive Disorder, Recurrent, Unspecified
Advancing Care Information (ACI)
▪ The Advancing Care Information score is the combined total of the following three scores:
Example: If a MIPS eligible clinician receives the base score (50%) and a 40% performance score and no bonus score, they would earn a 90% Advancing Care Information performance category score. When weighted by 25% (ACI Weighted score), this would contribute 22.5 points to their overall MIPS final score. (90 X .25 = 22.5).
▪ In order to receive the 50% base score, MIPS eligible clinicians must submit a “yes” for the security risk analysis measure, and at least a 1 in the numerator for the numerator/denominator of the remaining measures.
ACI
Advancing CareInformationTransition Objective
2017 Advancing Care InformationTransition Measure*
Required/ Not Requiredfor Base Score (50%)
Performance Score(Up to 90%)
ReportingRequirement
Protect PatientHealth Information
Security Risk Analysis Required 0 Yes/No Statement
Electronic Prescribing
E-Prescribing Required 0 Numerator/Denominator
Patient Electronic Access
Provide Patient Access Required Up to 20% - 2017Up to 10% - 2018
Numerator/Denominator
Patient Specific Education Not RequiredUp to 10% Numerator/
Denominator
Coordination of Care Through Patient Engagement
View, Download, or Transmit (VDT) Not RequiredUp to 10% Numerator/
Denominator
Secure Messaging Not Required Up to 10% Numerator/Denominator
Patient-Generated Health Data Not Required Up to 10% - 2018
Health InformationExchange
Send a Summary of Care Required Up to 20% - 2017Up to 10% - 2018
Numerator/Denominator
Request/Accept Summary of Care Required Up to 10% - 2018Clinical Information Reconciliation Not Required Up to 10% - 2018 Numerator/
Denominator
Medication Reconciliation Not Required Up to 10% - 2017 only Numerator/Denominator
ACI
Advancing CareInformation TransitionObjective
2017 Advancing CareInformation TransitionMeasure*
Required/Not Requiredfor Base Score(50%)
PerformanceScore (Up to90%)
Reporting Requirement
Public Health and Clinical Data Registry Reporting
Immunization RegistryReporting
Not Required 0 or 10% Yes/No Statement
Syndromic SurveillanceReporting
Not Required Bonus-2017 & 2018
Yes/No Statement
Electronic Case Reporting
Not Required Bonus-2018 only Yes/No Statement
Public Health Registry Reporting
Not Required Bonus-2018 only Yes/No Statement
Clinical Data Registry Reporting
Not Required Bonus-2018 only Yes/No Statement
Specialized Registry Not Required Bonus-2017 only
Bonus up to 15%Report to one or more additional public health and clinical dataregistries beyond the Immunization Registry Reporting measure
5% bonus Yes/No Statement
Report improvement activities using CEHRT 10% bonus Yes/No Statement
ACI Performance ScoringObjectives Patient Electronic
AccessCoordination of Care Through Patient Engagement
Health Information Exchange
MeasuresPatient Access
Patient Specific Education
VDTSecure Messaging
Patient-Generated Health Data
Patient Care Record Exchange
Request/ Accept Patient Care Record
Clinical Information Reconciliation
Perform
ance Rate S
core
90-100%
80-90% 91%
70-80%
60-70% 68% 64%
50-60%
40-50%
30-40%
20-30%
10-20% 13%0-10% 5% 6% 4%
Percentage Points Earned 6.8% 9.1% .05% 0.6% .04% 1.3% 6.4%
Total Performance Score 24.2%
Calculating the Final Score Under MIPS
Final Score=
Clinician Quality performance category score x actual Quality performance category weight
Clinician Cost performance category score x actual Quality performance category weight
Clinician Improvement Activities performance category score x actual Improvement Activities performance category weight
Clinician Advancing Care Information performance category score x actual Advancing Care Information performance category weight
Improvement Activities▪ Attest to participation in activities that improve clinical practice
▪ Clinicians choose from 90+ activities under 9 subcategories
Improvement Activities
▪ Special consideration for:
MIPS Scoring for Improvement Activities
Activity Weights
▪ Medium = 10 points
▪ High = 20 points
Full credit for clinicians in a patient-centered medical home, Medical Home Model, or similar specialty practice
Total points = 60
MIPS 2017
Not participating
in the Quality
Payment
Program:
If you don’t send in
any 2017 data, then
you receive a
negative 4%
payment
adjustment.
Test:
If you submit a
minimum amount of
2017 data to Medicare
(for example, one
quality measure or one
improvement activity
for any point in 2017),
you can avoid a
downward payment
adjustment.
Partial:
If you submit 90
days of 2017
data to
Medicare, you
may earn a
neutral or
positive
payment
adjustment.
Full:
If you submit a
full year of
2017 data to
Medicare, you
may earn a
positive
payment
adjustment.
Scoring
Creates 100-point
system to increase
and consolidate
financial impacts
Ranks peers
nationally, and
reports scores
publicly
2017 weightings put
85% in the Quality
and ACI categories
Resource Use is 0
for 2017, but will
be scored in 2018
and beyond
0POINTS
Resource
Use (Cost)
15POINTS
Clinical Practice
Improvement
Activities
25POINTS
Advancing
Care
Information
(Meaningful
Use)
60POINTS
Quality (PQRS/VBM)
ACI-2017
▪ In 2017, there are two measure set options for reporting:
– Advancing Care Information Objectives and Measures
– 2017 Advancing Care Information Transition Objectives and Measures
▪ The option you’ll use to send in data is based on your Certified EHR Technology edition
– To report on the first measure set requires 2015 Edition technology
– 2014 CEHRT may be used to report on the 2017 measure set
MIPS Scoring for Improvement Activities
Activity Weights
▪ Medium = 10 points
▪ High = 20 points
Alternative Activity Weights
▪ Medium = 20 points
▪ High = 40 points
For clinicians in small, rural, and underserved practices or with non-patient facing clinicians or groups
Full credit for clinicians in a patient-centered medical home, Medical Home Model, or similar specialty practice
2017 Requirement: Total points = 40
Calculating the Final Score Under MIPS (2017)
5 points x 8 measures=40points
40/80 possible points = 50%
[50% x 60% (MIPS weight)] x 100= 30 points
Bonus- Up to 6 bonus points possible
= 36 total points
Quality Improvement Activities
40 points out of 40 possible points = 100%
[100% x 15% (MIPS weight)] x 100 = 15total points
74.7points/100 possible points=74.7%
[74.7% x 25% (MIPS weight)] x 100 = 18.66 total points
Final Score
36 + 15 + 18.66= 69.66Points
ACI
Transition Year 2017
Final Score Payment Adjustment
≥70 points • Positive adjustment• Eligible for exceptional performance bonus-minimum of
additional 0.5%
4-69points
• Positive adjustment• Not eligible for exceptional performance bonus
3 points • Neutral payment adjustment
0 points • Negative payment adjustment of -4%• 0 points=does not participate
Medicaid EHR Incentive Program and MIPS
▪ Separate program from MIPS
▪ The Medicaid EHR Incentive Program will provide incentive payments to providers for a total of 6 year, with 2016 the last year to begin the program
– Provider began program in 2012, would receive incentives through reporting year 2017
– Provider began program in 2016, would receive incentives through reporting year 2021
▪ In 2017, providers will be attesting to Modified Stage 2
– Very similar to 2016, with two objectives having higher thresholds
▪ Providers still retaining eligibility in the Medicaid EHR program who also bill Medicare Part B services may/will attest for both the Medicaid EHR program and MIPS
▪ Medicaid meaningful use objectives may/may not align with the MIPS Advancing Care Objectives
▪ Requires attestation through two separate reporting mechanisms
Medicaid EHR Incentive Program and MIPS
Improvement Activities
The key to moving towards value and quality
What is an Improvement Activity
▪ An activity that stakeholders identify as “improving clinical practice or care delivery”
▪ Focuses on CMS’ strategic goals to use a “patient-centered approach to program development that leads to better, smarter, and healthier care
Improvement Activities
▪ CMS makes it clear that the first year will be the “easiest” year for Improvement Activities. They hope to create baseline requirements the first year and then build more stringent requirements in future years, laying the groundwork for expansion towards continuous improvement over time
▪ In future years, CMS proposes to assign scores based on providers’ performance or improvement on CPIAs
Improvement Activities
▪ Improvement activities are foundational to MIPS (and/or MU)
– Formal, systematic approach to:▪ Analysis of practice performance
▪ Efforts to improve performance
▪ Many times we fly by seat of out pants due to lack of time/resources
– Reality Check: It takes planning to succeed
▪ It takes time to strategize and implement performance improvements, including partnerships and technology.
▪ This gives us opportunity to lay and document groundwork for real improvement (and get credit for it)
Improvement Activities-Getting Started
1. Choose measures to maximize score
– Relevant to your scope of practice
– Can demonstrate improvement
– Compliments other current work
– Doable
Improvement Activities-Getting Started
2. Plan implementation
Data sources/technology
Patient outreach
Workflow – integrate don’t layer
Staff training
Community partners
Improvement Activities-Getting Started
3. Documentation
– Who
– How
– When
Sample Improvement Activities
Track Patients Referred to Specialist through the Entire Process (Medium)
Background
▪ High fragmentation of health care delivery systems
▪ Referral tracking provides opportunity to improve communication and coordination between all providers
▪ Many obstacles to achieving referral tracking:
– Volume of referrals
– EHR inefficiencies
– Lack of staff
– Cumbersome processes
– Challenging population that often does not keep appointments
Track Patients Referred to Specialist through the Entire Process (Medium)
Purpose
▪ Specialist receives necessary information for referral appointment in a timely manner
▪ Increased percentage of patients showing for referral appointment
▪ Documentation is received from the specialist and integrated into the patient’s EHR chart
▪ Decrease number of patients who “fall through the cracks”
Improvement Activity aligns with the following MIPS or Medicaid MU requirements
▪ Advancing Care Information Objectives:
– Health Information Exchange Objective
▪ Send a Summary of Care Record
▪ Request/accept Summary of Care Record
▪ Clinical Information Reconciliation (2017-Medication Reconciliation)
▪ Quality Measure
– Closing the Referral Loop; Receipt of Specialist Report (CMS 50v5) (High)
Track Patients Referred to Specialist through the Entire Process (Medium)
MU
MUMU-Stage 3
MU
Plan Details
▪ Document baseline data
▪ Assign project coordinator responsible for implementation of improvement activity
▪ Confirm Names/Roles of staff included in process
▪ Provide education on:
– How to document referral (in EHR or manually)
– How to create and electronically exchange the summary of care record
– How to run referral reports or review of manual documentation
– How to integrate specialist’s documentation into EHR
– How to perform and document Clinical Information Reconciliation
– How to “close loop” of referral process
▪ Monitor reports/results monthly
Track Patients Referred to Specialist through the Entire Process (Medium)
Track Patients Referred to Specialist through the Entire Process (Medium)
Provide 24/7 access to eligible clinicians or groups who have real-time access to patient's medical record
Improvement Activity aligns with the following MIPS or Medicaid MU requirements:
- Potential impact on episode cost
- Quality Measures (some of them)
• Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (CMS 2)
• Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (CMS 177)
• Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (CMS 161)
Provide Peer-led support for self-management
Improvement Activity aligns with the following MIPS or Medicaid MU requirements:
- Potential impact on episode cost
- Advancing Care Information Objectives:Patient Portal
▪ View, Download, or Transmit
▪ Secure Messaging
▪ Patient-generated Health Data
- Quality Measure
– Anti-Depressant Medication Management (CMS 128 v5)
Improvement Activity aligns with the following MIPS or Medicaid MU requirements
▪ Will Enhance Score on the Following Advancing Care Information Objective:
– Coordination of Care Through Patient Engagement
▪ View, Download, or Transmit
▪ Secure Messaging
▪ Patient-generated Health Data
▪ Quality Measure
– CAHPS for PQRS (MIPS) Clinician/Group Survey (NQF: 0006 & 0005) (High)
Collection & Follow-up on Patient Experience & Satisfaction Data on Beneficiary Engagement, including Development of Improvement Plan (High)
MUMU
MU-2018
How do these measures relate to a Behavioral Health Agency?
What do you think might be easy to implement?
What measures might be more challenging?
What measures do you think will lead to improved quality?
What could lead to more efficient services?
Final Thoughts
▪ MIPS is doable
▪ Select/empower a MIPS team
▪ Complete the MIPS Questionnaire
▪ Review all know data
– Meaningful Use objective percentages
– PQRS Feedback reports
– QRUR reports
Resources▪ CMS Quality Payment Program Resources
– https://qpp.cms.gov/
▪ CMS-MIPS Scoring Methodology Overview
– https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-Scoring-Methodology-slide-deck.pdf
▪ Introduction to the QPP and MIPS-HealthIT
– https://www.healthit.gov/FACAS/sites/faca/.../HITJC_QPP_Review_2016-12-06.pptx
▪ SA Ignite-The ABCs of MIPS Webinar Series
– http://www.saignite.com/resources/hitech-abc-of-mips-webinar
▪ National Council for Behavioral Health-MACRA Resources
– https://www.thenationalcouncil.org/macra/
▪ American Psychiatric Association-Payment Reform Toolkit
– https://www.psychiatry.org/psychiatrists/practice/practice-management/coding-reimbursement-medicare-and-medicaid/payment-reform
Thank You
▪ Cindy Buege, CPHIMS, CHPS, Project Manager [email protected]
▪ Krista Hauserman, , LMSW, CAADC, HIT Specialist [email protected]
