Merit-Based Incentive Payment System: 2018 Performance Year

Knowledge Brief Merit-Based Incentive Payment System: Performance Year The Merit-based Incentive Payment System (MIPS) impacts the 2020 Medicare Part B payment for billed visits in calendar year. MIPS is one aspect of the Centers for Medicare and Medicaid Services Quality Payment Program; it is intended to prepare clinicians for participation in Advanced Alternative Payment Models by shifting from a volume-based payment system to one that is based on value. Patient experience surveying improves scoring opportunities in the Quality and Clinical Practice Improvement Activities measure categories. Overview The 2015 Medicare Access and CHIP Reauthorization Act (MACRA) repealed the Sustainable Growth Rate payment methodology for physician services. MACRA combined the Physician Quality Reporting System (PQRS), Electronic Health Record Meaningful Use (EHR MU) criteria, and Value-Based Payment Modifier (VBPM) program requirements into a payment incentive program called the Quality Payment Program (QPP). Eligible clinicians can meet QPP requirements by participating in either Advanced Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS). The Centers for Medicare and Medicaid Services (CMS) encourages Advanced APM participation because it anticipates this model will result in higher quality care by improving care coordination and customization. Qualified Advanced APM participants those with at least 25% of their Medicare Part B services or at least 20% of their Medicare beneficiaries covered through an Advanced APM will receive annual incentive payments, in addition to payment for services furnished, equal to 5% of their aggregate payment amounts for Medicare-covered professional services in the preceding year. Incentive payments begin in the 2019 payment year and continue through 2024 after which a 0.75% rate increase will be implemented annually. Clinicians who are not qualified participants in Advanced APMs will have Medicare Part B reimbursement rates determined under the MIPS program. The MIPS program provides financial incentives to eligible clinicians (ECs) to increase engagement with patients, families, and caregivers; to improve care coordination; and to advance improvements in population health. ECs participating in an APM not qualified as an Advanced APM are subject to Medicare payment determinations based on MIPS scores in addition to any APM-specific financial incentives. The Advanced APM is the national vision for a physician practice care model. MIPS is intended to prepare eligible clinicians for participation in APMs by improving the capacity to meet benchmarks for quality, clinical practice improvement, meaningful use of Certified EHR Technology (CEHRT), and resource use (cost). To help ECs participate successfully in MIPS and allow time for processes to be developed, CMS continues to offer program flexibility in. 2017 Press Ganey Associates, Inc. 1

MIPS Eligible Clinicians For the performance year, the MIPS program includes five clinician types (referred to as eligible clinicians, or ECs). These clinician types are unchanged from the 2017 performance year. Additional clinician types should anticipate required participation in the 2019 performance year (Table 1). All clinician types can participate voluntarily; data submission will not impact reimbursement if submitted on a voluntary basis. Table 1. Eligible Clinician Participation Requirements Years 1 & 2 ECs (2017 & Performance Years) Advanced Practice Nurses Certified Registered Nurse Anesthetists Clinical Nurse Specialists Physician Assistants Physicians Includes non-patient-facing ECs* Year 3 ECs (2019 Performance Year) Physical Therapists Occupational Therapists Speech-Language Therapists Audiologists Certified Nurse Midwives Clinical Social Workers Clinical Psychologists Registered Dietitians Excluded ECs New clinicians: First year enrolled in Medicare Part B Small practices: Medicare charges of < $90,000 or < 200 Part B Medicare beneficiaries Advanced APM participants: Collect > 25% of Medicare payments or see > 20% of Medicare patients through the Advanced APM *Definition of non-patient-facing ECs: Individal ECs who bill 100 or fewer patient-facing encounters, and groups with more than 75% of the TIN participants billing 100 or fewer patient-facing encounters. To support the Patients Over Paperwork Initiative aimed at removing regulatory obstacles that get in the way of providers spending time with patients CMS is excluding additional small practices in by increasing the low volume thresholds to less than or equal to $90,000 in Medicare Part B charges, or less than or equal to 200 Medicare Part B patients. Participating small practices (groups of 15 or fewer ECs who exceed the small volume threshold) will be awarded five bonus points toward the final MIPS score. Additionally, small practices will continue to earn three points in the Quality category even if minimum submission requirements are not met, and are eligible for a significant hardship exemption relative to CEHRT adoption. If a significant hardship exemption is granted, three points will be awarded in the Advancing Care Information category even if minimum submission thresholds are not met in that category. The MIPS program allows for individual EC participation, group participation, and virtual group participation. The payment adjustment for ECs submitting MIPS data as individuals is based on the individual EC s performance. ECs submitting MIPS data as a group will receive a payment adjustment based on the group s performance. A group is defined as two or more clinicians (with unique National Provider Identifiers) who bill under a single Tax Identification Number (TIN). The opportunity to participate as a virtual group is new for the performance year. Individual ECs and groups of ten or fewer ECs, that bill under different TINs, can 2017 Press Ganey Associates, Inc. 2

choose to participate collaboratively as a virtual group. This requires a formal, written agreement among all virtual group participants. See the CMS Virtual Groups Toolkit. Individual ECs: Submit individual EC data for each of the MIPS categories Payment adjustment is based on individual MIPS Score Report data through EHR, Registry, a Qualified Clinical Data Registry, or Medicare Part B claims. Groups (including Virtual Groups): Submit group-level data for each of the MIPS categories Individual EC payment adjustments are based on the group s performance Report data through EHR, Registry or a Qualified Clinical Data Registry Groups of 25 or more can report through CMS Web Interface For the performance year, ECs must make an election to participate as an individual, a group, or a virtual group by December 31, 2017. CMS will identify MIPS ECs; non-patient facing clinicians; and small, rural, and Health Professional Shortage Area (HPSA) practices. ECs will no longer self-identify their status. See the guides in the Resources section of this document for help with MIPS registration. Patient-centered medical homes (or comparable specialty practices) receive full credit for the 2020 MIPS payment year. CMS defines an EC or group as a certified patient-centered medical home if at least 50 percent of the practice sites within the TIN are recognized as such. Financial Impact The MIPS program rules will first be applied to 2019 Medicare Part B payments for services, activities, and outcomes relative to the 2017 performance period. This is referred to as year one. The performance period or year two will affect 2020 Medicare Part B payments. For the performance year, the financial impact is increased to a ±5% maximum payment adjustment for the 2020 payment determination and increases to ±9% for the 2022 payment determination (Table 2). There is an imperative for practices to understand the high-risk MIPS poses for undermining financial viability if data submission requirements are not met. Table 2. Maximum MIPS Financial Impact by Payment Year Payment Year 2019 2020 2021 2022 Performance Year 2017 2019 2020 Maximum Payment Adjustment ±4% ±5% ±7% ±9% MIPS Performance Categories There are four performance categories in the MIPS program paradigm; three categories require data submission, and each is weighted differently toward the overall score: Quality, Clinical Practice Improvement Activity, Advancing Care Information, and Cost (Figure 1). The category weights vary by year and will continue to evolve through rulemaking. 2017 Press Ganey Associates, Inc. 3

Figure 1. MIPS Category Weights by Performance Year/Payment Year 2017 / 2019 / 2020 2019 / 2021 Quality Clinical Practice Improvement Activity Advancing Care Information Cost A notable exception to the weights depicted in Figure 1: For the performance year, the Advancing Care Information category is weighted zero for non-patient-facing ECs, and the 25% weight is reallocated to the quality category. The different categories provide different perspectives on care delivered in the medical practice setting. Each is subject to its own rules for measure selection and data submission. Patient experience surveying can be used as a measure of performance in two categories: Quality and Clinical Practice Improvement Activity (CPIA). The Quality Category measures health outcomes and adherence to evidence-based practice. Participants earn up to 10 points for each measure submitted. There are three options to maximize scoring in this category: 1. Select six quality measures: ECs and groups must submit six quality measures selected from a pool of over 300 evidence-based measures. One of these measures must be an outcome measure. If there is no applicable outcome measure, one of the six quality measures must be a high-priority measure. The MIPS Consumer Assessment of Healthcare Providers and Systems (MIPS CAHPS) survey counts as a high-priority quality measure. ECs and groups may opt to submit more than six quality measures in which case the highest scoring six measures will be applied to the quality category score. If fewer than six quality measures pertain to the patient population, submit all that apply. 2. Select a specialty-specific measure set: ECs and groups have the option to submit a pre-defined measure set specific to their specialty. There are 34 specialty-specific measure sets for the performance year pre-loaded with all the measures applicable to the specialty (see Appendix A). If the measure set has more than six measures, the EC or group may select six for submission, including one outcome measure if available. If no outcome measure is available in the set, submit a high-priority measure. Participants may opt to submit more than six measures (the highest scoring six measures will be applied to the MIPS quality category score). If there are six or fewer measures in the set, submit them all. 2017 Press Ganey Associates, Inc. 4

3. Select the CMS web interface measure set: Participants submitting quality measures via the CMS web interface must submit all measures pre-loaded into the interface mechanism for the first 248 ranked and assigned Medicare beneficiaries as provided by CMS. If the sample provided is less than 248, submit all measures for all cases. Quality measures with benchmarks that have been topped out for at least two consecutive years will earn participants a maximum of seven points each and will be phased out over four years. Topped out policies do not apply to CMS Web Interface measures. For the performance year, there are six topped out quality measures: 1. Perioperative Care: Selection of Prophylactic Antibiotic-First or Second Generation Cephalosporin (Quality Measure ID 21) 2. Melanoma: Overutilization of Imaging Studies in Melanoma (Quality Measure ID 224) 3. Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) (Quality Measure ID 23) 4. Image Confirmation of Successful Excision of Image-Localized Breast Lesion (Quality Measure ID 262) 5. Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT) Imaging Description (Quality Measure ID 359) 6. Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy (Quality Measure ID 52) The All-Cause Hospital Readmission (ACR) measure is calculated for groups with 16 or more ECs with at least 200 cases billed in the performance year. This is a claims-based measure that does not require data submission on the part of the group. The ACR measure does not count toward the six measure requirement; it is calculated in addition to any quality measures submitted. The ACR rate will be applied to the quality category score even if no quality measures are submitted. MIPS participants can earn up to 10 bonus points in this category by submitting additional high-priority and outcome measures. MIPS CAHPS (available to groups) is worth two bonus points, other high-priority measures are worth one bonus point each, and every additional outcome measure submitted is worth two bonus points each. MIPS CAHPS is a high-priority quality measure available to ECs reporting as a group. For the performance year, interested groups must indicate intent to participate in MIPS CAHPS on the CMS MIPS program registration website by June 30,. The MIPS CAHPS survey includes the CAHPS Clinician and Group survey with additional questions (Table 3). CMS has removed two summary survey modules beginning with the performance year: Helping You Take Medication as Directed, and Between Visit Communication. CMS requires collection through a CMS-certified vendor. Table 3. MIPS CAHPS Summary Survey Modules MIPS CAHPS Summary Survey Modules Getting Timely Care, Appointments, and Information How Well Providers Communicate 2017 Press Ganey Associates, Inc. 5

Patient s Rating of Provider Access to Specialists Health Promotion and Education Shared Decision-Making Health Status and Functional Status Courteous and Helpful Office Staff Care Coordination Stewardship of Patient Resources Press Ganey is a certified MIPS CAHPS vendor. The survey is administered annually; MIPS CAHPS surveying must span between eight and seventeen weeks ending no later than February 28 following the performance year. Press Ganey will distribute MIPS CAHPS surveys November through February 2019 for the 2020 payment determination. CMS indicates it is considering requiring MIPS CAHPS in future performance years. Given the significance of the surveys in CMS quality initiatives, understanding your position in MIPS CAHPS and targeting improvements before mandatory MIPS CAHPS performance evaluations are introduced is a valuable strategy. Furthermore, CMS values high-priority measures and provides incentives for selection and submission of these measure types. MIPS CAHPS is a high-priority measure. As such, participation earns groups two bonus points in the quality category score and provides several opportunities for groups to meet CPIA measure requirements. Accountable Care Organizations (ACOs) in Advanced Alternative Payment Models are not subject to MIPS. ACOs in APMs not qualified as Advanced (MIPS APMs) are subject to MIPS. However, CMS has defined a special APM Scoring Standard for the MIPS APMs. The data required to participate in the APM counts as the MIPS Quality and CPIA data for these ECs. The Clinical Practice Improvement Activities Category encourages improvement activities associated with better-quality health outcomes. In, MIPS participants select from a list of 112 activities in eight subcategories: 1. Achieving Health Equity (6 activities 2 new) 2. Behavioral and Mental Health (9 activities 1 new) 3. Beneficiary Engagement (23 activities) 4. Care Coordination (17 activities 3 new) 5. Emergency Response and Preparedness (2 activities) 6. Expanded Practice Access (5 activities 1 new) 7. Patient Safety and Practice Assessment (30 activities 9 new) 8. Population Management (20 activities 6 new, 1 removed) For the performance year, CMS removed PM_8: Participation in Capability Maturity Model Integration from the Population Management subcategory, added 24 new activities, and modified 27 2017 Press Ganey Associates, Inc. 6

existing activities. ECs should aim to earn 40 CPIA points by selecting any combination of activities each worth either 10 or 20 points with the following exceptions: Small practices, providers designated as rural or HPSAs, and non-patient facing participants need only 20 points to maximize scoring in this category. APMs participating in MIPS those who are not qualified participants in Advanced APMs must earn only 30 CPIA points to maximize their score in this category. Patient-centered medical homes are awarded all 40 points; no data submission is required in this category. Reaching 40 CPIA points maximizes the potential score in this category for the majority of MIPS participants. ECs are not required to submit enough CPIA measures to reach 40 points, but the impact on the overall MIPS score, and thereby on reimbursement, provides a significant incentive to do so. If reporting as a group, the group may submit any CPIA as long as at least one member of the group performed the activity for at least 90 consecutive days in. Collecting MIPS CAHPS data and providing action plans to target improvements in patient engagement and communication can readily earn a participant the 40 points targeted for the CPIA category (Table 4). MIPS CAHPS also counts as one Quality category measure, serves as a high-priority quality measure, and earns two bonus points on the Quality category. Therefore, MIPS CAHPS participation helps groups meet multiple program requirements and boosts scores. Table 4. Using Patient Experience Data to Meet CPIA Requirements CPIA Category Activity Weight Patient Safety and Practice Assessment Patient Safety and Practice Assessment Patient Safety and Practice Assessment Patient Safety and Practice Assessment Participation in the Consumer Assessment of Healthcare Providers and Systems survey or other supplemental questionnaire items. Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities. This could include sharing quality of care, patient experience, and utilization data with staff, patients, and families to promote transparency and accelerate improvement. Ensure full engagement of clinical and administrative leadership in practice improvement. This could include incorporating population health, quality, and patient experience metrics in regular reviews of practice performance. Measure and improve quality at the practice and panel level that could include one or both of the following: Regularly review measures of quality, utilization, patient satisfaction, and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group Use relevant data sources to create benchmarks and goals for performance. 20 points 10 points 10 points 10 points 2017 Press Ganey Associates, Inc. 7

CPIA Category Activity Weight Expanded Practice Access Beneficiary Engagement Beneficiary Engagement Beneficiary Engagement Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs. Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan. Regularly assess the patient experience of care through surveys, advisory councils, and/or other mechanisms. Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement. 10 points 20 points 10 points 10 points The included activities do not require Certified Electronic Health Record Technology (CEHRT) to complete. However, ECs and groups who can attest to using CEHRT functionality to complete a selected activity will earn 10 bonus points toward the Advancing Care Information category score. The activities list has increased in year two and includes 30 activities that allow for the CEHRT bonus in the performance year. The Advancing Care Information Category measures use of technology for interoperability and information exchange. Participants can earn up to 100 points in this category. The category score is determined in three parts: Base Score + Performance Score + Bonus Points. The Base Score is worth 50 points. Participants will earn all 50 points or none. To earn the base points, the Security Risk Analysis measure must be answered yes, and the remaining required measures must have at least one in the numerator. Only participants who meet the base point criteria will be eligible to earn performance points (see the Performance Score column in Tables 5 and 6). In the performance year to maintain flexibility for ECs unable to implement the 2015 edition CEHRT ECs will continue to have the option to report the Advancing Care Information Transition Measure set from the 2017 performance year (Table 6), or for ECs acquiring the necessary 2015 edition CEHRT capabilities the performance year Advancing Care Information Objectives and Measures (Table 5) using 2014 Edition CEHRT, 2015 Edition CEHRT, or a combination of the two. Measure selection in this category depends in part on the CEHRT edition in use. Some ECs and groups may be using a combination of CEHRT editions and will have the opportunity to select from across either measure set. ECs will earn a 10 point bonus for using only the 2015 CEHRT in the MIPS performance year. 2017 Press Ganey Associates, Inc. 8

Table 5. Performance Year Advancing Care Information Objectives and Measures Objective Measure Required for Base Score Performance Score Reporting Standard Protect Patient Health Information Security Risk Analysis Yes 0 Yes/No Electronic Prescribing e-prescribing Yes 0 Numerator/Denominator Health Information Exchange Patient Electronic Access Send a Summary of Care Request/Accept Summary of Care Clinical Information Reconciliation Provide Patient Access Patient-Specific Education Yes Up to 10 points Numerator/Denominator Yes Up to 10 points Numerator/Denominator No Up to 10 points Numerator/Denominator Yes Up to 10 points Numerator/Denominator No Up to 10 points Numerator/Denominator Coordination of Care Through Patient Engagement View/Download/or Transmit No Up to 10 points Numerator/Denominator Secure Messaging No Up to 10 points Numerator/Denominator Public Health & Clinical data Registry Reporting Patient Generated Health Data Immunization Registry Reporting Syndromic Surveillance Reporting Electronic Case Reporting Public Health Registry Reporting No Up to 10 points Numerator/Denominator No Zero or 10 points* Yes/No No Zero or 10 points* Yes/No No Zero or 10 points* Yes/No No Zero or 10 points* Yes/No Clinical Data Registry Reporting No Zero or 10 points* Yes/No Requires 2015 Edition. * Participants earn 10 performance points for reporting to any single public health agency or clinical data registry. An additional five bonus points are awarded for reporting to more than one. 2017 Press Ganey Associates, Inc. 9

Table 6. Transition Advancing Care Information Objectives and Measures Objective Measure Required for Base Score Performance Score Reporting Standard Protect Patient Health Information Security Risk Analysis Yes 0 Yes/No Electronic Prescribing e-prescribing Yes 0 Numerator/Denominator Health Information Exchange Medication Reconciliation Patient Electronic Access Patient-Specific Education Health Information Exchange Clinical Information Reconciliation Medication Reconciliation Provide Patient Access View/Download/or Transmit Patient-Specific Education Yes Up to 10 points Numerator/Denominator No Up to 10 points Numerator/Denominator No Up to 10 points Numerator/Denominator Yes Up to 20 points Numerator/Denominator No Up to 10 points Numerator/Denominator No Up to 10 points Numerator/Denominator Secure Messaging Secure Messaging No Up to 10 points Numerator/Denominator Public Health Reporting Immunization Registry Reporting Syndromic Surveillance Reporting Specialized Registry Reporting No Zero or 10 points Yes/No No Zero or 10 points Yes/No No Zero or 10 points Yes/No Not all ECs in a group need to contribute data to the selected measures in this category. Only one EC in a group needs to be collecting data relative to each selected measure. However, groups should submit all available data for each selected measure. If none of the Advancing Care Information measures apply to a participating EC or group, or if an EC or group can demonstrate significant hardship in implementing health information technology, CMS will reweight the category to zero and assign the 25% weight to other performance categories to offset the difference in the MIPS final score. 2017 Press Ganey Associates, Inc. 10

The Cost Category measures and compares costs to treat Medicare beneficiaries. For, the MIPS cost category includes the Medicare Spending per Beneficiary measure and the total per capita cost measure. CMS is retiring the 10 episode-based measures from this category for the performance year. New episode-based cost measures are under development for consideration for future years. This category is claims based; no data submission is required. Note that the cost measures bear a 10% weight toward the overall score for the performance year. This is an increase from a weight of zero in program year one. It will increase to a 30% weight in the 2019 performance year. Data Submission There are a variety of data-submission methods that vary in availability depending on the data category. The number of measures, minimum case requirements, claims type, collection timeframes, and deadlines also vary depending upon the data category and submission method (Table 7). CMS encourages participants to submit all measures in a category via one submission mechanism. However, it is acceptable (and sometimes necessary) to select different submission mechanisms for different categories. Table 7. Data Submission Requirements for the Performance Year Data Category Data Submission Mechanism No. of Required Measures Minimum No. of Cases to Submit Claims Type Data Collection Timeframe Data Submission Timeline Quality QCDR Qualified Registry CEHRT Up to six 60% of patients meeting the denominator criteria All payer Full CY January 1 - March 31, 2019 Part B Claims* Up to six 60% of patients meeting the denominator criteria Medicare Part B Full CY claims processed by Jan 29, 2019 CMS Web Interface** All measures prepopulated in the CMS Web Interface The first 248 cases listed If fewer than 248 submit all cases provided Medicare Part B Full CY An eightweek period between January 1 and March 31, 2019 CMS Certified Vendor MIPS CAHPS Meet survey sample requirement Medicare Part B Full CY Distributed November - February 2019 2017 Press Ganey Associates, Inc. 11

Data Category Data Submission Mechanism No. of Required Measures Minimum No. of Cases to Submit Claims Type Data Collection Timeframe Data Submission Timeline Claims All Cause Hospital Readmission Measure N/A Medicare Part A & B Full CY Submit all claims by Jan 29, 2019 Cost Management N/A Two 20 cases for each measure Medicare Part A & B Full CY Submit all claims by Jan 29, 2019 Advancing Care Information Attestation QCDR Qualified Registry CEHRT Four in the Transition measure set Five in the measure set A Yes answer, or one case in each measure numerator N/A Any 90 consecutiv e days in Up to a full CY of data January 1 - March 31, 2019 CMS Web Interface** Full CY Clinical Practice Improvement Activity Attestation QCDR Qualified Registry CEHRT Up to four One affirmative attestation for each activity N/A Any 90 consecutiv e days in Up to a full CY of data January 1 - March 31, 2019 CMS Web Interface** Full CY * Individual ECs only; ** Groups of 25 or more; Plus an attestation that a third party is submitting on your behalf if this is this case. Groups submitting data via the CMS Web Interface and groups opting to submit MIPS CAHPS data must register for those options via the CMS Enterprise Portal by June 30,, for the performance period. Data completeness for virtual groups applies cumulatively across all TINs in a virtual group. For the performance year, quality and cost categories require a full CY data. The CPIA and Advancing Care Information categories maintain the minimum 90-consecutive day performance period. Scoring Each submitted measure is scored based on comparison to national benchmarks. The measures within each category are then summed to a category score, and the category scores are given a weight toward the overall MIPS score. The overall score is then compared to a national performance threshold (PT) that is determined annually based on the average MIPS composite score nationally. Payment adjustments are based on a sliding scale relative to the quartile of performance as compared to the PT (Figure 2). Final scores at or below 3.75 will result in the full -5% downward payment. 2017 Press Ganey Associates, Inc. 12

Figure 2. MIPS 2019 Payment Year Adjustment Range Each measure category uses a different scoring methodology. Quality Score In the Quality category, each submitted measure earns from three to 10 achievement points depending on performance against national benchmarks. Beginning with the performance year, for measures that have two years of data available, an improvement score is calculated based on the rate of increase in the achievement score year to year 1. CMS allowances for the performance year: Any quality measure submitted via Part B Claims, CMS Web Interface, or CMS Certified Vendor that does not meet minimum case requirements will earn three points. Any quality measure submitted via EHR, QCDR, or qualified registry that does not meet minimum case requirements will earn one point. Any quality measure submitted by a small practice that does not meet minimum case requirements regardless of submission mechanism will earn three points. The category score is calculated by first adding points earned for the six submitted measures, the ACR, and bonus points, then dividing the sum by the number of measures submitted times ten, plus the number of improvement points earned. The category score cannot exceed 100. [Achievement points earned on quality measures] + [ACR] + [Bonus points] 6 required measures x 10 + Improvement Points 1 This provides an incentive for eligible clinicians to focus on improvement by allowing for extra points when the same measures are submitted year after year and improvement is demonstrated. 2017 Press Ganey Associates, Inc. 13

Clinical Performance Improvement Activity Score The CPIA category score first determines the points for each submitted activity (10 or 20). The total number of points is divided by 40 (the maximum points for ) and multiplied by 100. Points earned from submitted activities 40 maximum points x 100 Exceptions for the performance year: Small practices, rural, HPSAs, and non-patient facing ECs calculate the score with a denominator of 20. APM participants (not qualified as Advanced APMs) calculate the score with a denominator of 30. Patient-centered medical homes are awarded all 40 points. Advancing Care Information Score The Advancing Care Information category relies on receiving the 50 base points by successfully submitting the required measures. Participants who do not meet the submission requirements for those measures will be scored zero in this category. Those who do acquire the 50 base points will then be assessed for performance and bonus points. Base score (50) + Performance score (max 90) + Bonus score (max 15) Cost Score In the Cost category, each measure earns between one and 10 points based on the EC s decile of performance compared to the measure benchmarks. National deciles of performance are calculated using data from the performance period. The category score is the average of the two included measures. Beginning with the performance year, for measures that have two years of data available, an improvement score is calculated based on the rate of increase in the achievement score year to year 2. Achievement points earned from submitted measures Two measures + Improvement Points 2 This provides an incentive for eligible clinicians to focus on improvement by allowing for extra points when the same measures are submitted year after year and improvement is demonstrated. 2017 Press Ganey Associates, Inc. 14

Earning Bonus Points There are various ways for MIPS participants to earn bonus points toward the final MIPS score (Table 8). Table 8. MIPS Bonus Points for the Performance Year Category Bonus Points Earning Bonus Points Final Score: Small Practice Bonus 5 Points EC or group defined as a small practice (in a group of 15 or fewer ECs) that submits data for at least one performance category. Final Score: Complex Patients Bonus Up to 5 Points Clinicians can earn up to 5 bonus points for the treatment of complex patients (based on a combination of the Hierarchical Condition Categories (HCCs) and the number of dually eligible patients treated). Quality Category Score 1 Point (Max 10) For every high-priority or outcome measure submitted beyond basic requirements (including MIPS CAHPS). 2 Points Groups that submit MIPS CAHPS. Advancing Care Information Category Score 10 Points Attest to using CEHRT functionality to complete an improvement activity (applied to 18 specified improvement activities only). 5 Points For reporting to an additional public health or clinical data registry measure beyond those required for the Advancing Care Information performance score. 10 Points Use only 2015 edition CEHRT in. MIPS Score Although some category scores can exceed 100, MIPS category scores and the overall score are all capped at 100. To calculate the final, overall MIPS score each category score is multiplied by its weight and these weighted category scores are summed. The scoring for the performance year is as follows: ([Quality category score x 50%] + [CPIA category score x 15%] + [Advancing Care Information category score x 25%] + [Cost category score x 10%] + Bonus Points) x 100 Multiply either each category score or the overall score by 100 to convert from a percentage to a point value. See Appendix B for a scoring example. 2017 Press Ganey Associates, Inc. 15

For performance year, the PT is set at 15 points. This is the breakeven point. Scoring below this threshold will result in a downward payment adjustment, scoring at or above this threshold in the MIPS performance year will prevent a downward adjustment for the 2020 payment determination. Submitting the full set of requirements six quality measures, five Advancing Care Information measures, and enough CPIA measures to reach the 40-point threshold will better position participants for a positive adjustment. Those attaining a final score of 70 or better will receive an additional MIPS payment adjustment factor and may share in the $500 million available for exceptional performers (Table 9). Table 9. 2020 Payment Adjustment Based on Performance Year MIPS Score Final Score > 70 Points 16 69 Points Payment Adjustment Positive adjustment Eligible for exceptional performance bonus minimum of additional 0.5% Positive adjustment up to +5% Not eligible for exceptional performance bonus 15 Points Neutral, no payment adjustment 3.76 14 Points Negative payment adjustment up to -5% 0-3.75 Points -5% Negative Payment Adjustment Failing to reach the 15 point performance threshold for the performance year will result in a reduction in Medicare Part B reimbursement for the 2020 payment year. Participants should anticipate more stringent participation requirements and higher financial risk in future years. MIPS data will be publicly reported on Physician Compare beginning with the 2017 performance year data. The date of publication is to be determined and may vary by measure type. Conclusion A great deal of flexibility was maintained for EC participation in the MIPS program year. However, the financial stakes are higher, and CMS has built-in significant incentives for clinicians to develop integrated care models including patient engagement and to advance health information technology capabilities. Submitting additional measures and taking advantage of bonus points will help participants achieve an upward payment adjustment. Meeting all requirements greatly improves the odds of receiving an upward payment adjustment, and exceeding requirements increases the odds of receiving additional highperformer incentive funds. The MIPS program intends to advance national goals for improving the quality of health care by increasing patient engagement and patient-centeredness, and supporting an outcome-focused, resourceefficient health system. To intensify efforts to improve the patient experience, CMS has designed strategic advantages to participating in MIPS CAHPS. Groups participating in MIPS CAHPS meet multiple measure requirements across Quality and Clinical Practice Improvement Activity categories and earn two bonus points toward the Quality category score, which has a direct impact on the 2020 payment determination. 2017 Press Ganey Associates, Inc. 16

Resources CMS Quality Payment Program CMS Quality Payment Program Resource Library CMS Quality Payment Program Educational Webinars MIPS Participation Requirements by National Provider Identifier Guide for Obtaining a New EIDM Account with a Physician Quality and Value Programs Role Guide for Obtaining a Physician Quality and Value Programs Role for an Existing EIDM User 2017 Press Ganey Associates, Inc. 17

Appendix A: Specialty Measure Sets MIPS Specialty Measure Sets for the Performance Year 1. Allergy / Immunology 2. Anesthesiology 3. Cardiology 4. Gastroenterology 5. Dentistry 6. Dermatology 7. Diagnostic Radiology 8. Electrophysiology Cardiac Specialist 9. Emergency Medicine 10. Family Medicine 11. General Surgery 12. Hospitalist 13. Infectious Disease 14. Internal Medicine 15. Interventional Radiology 16. Mental / Behavioral Health 17. Nephrology 18. Neurology 19. Neurosurgery 20. Obstetrics / Gynecology 21. Ophthalmology 22. Orthopedic Surgery 23. Otolaryngology 24. Pathology 25. Pediatrics 26. Physical Medicine 27. Plastic Surgery 28. Podiatry 29. Preventive Medicine 30. Radiation Oncology 31. Rheumatology 32. Thoracic Surgery 33. Urology 34. Vascular Surgery 2017 Press Ganey Associates, Inc. 18

Appendix B: Scoring Example for a Medium Size Practice Performance Category [A] Performance Score [B] Category Weight [C] Earned Points [B]*[C]*100 Quality 75% 50% 37.5 Cost 50% 10% 5 Improvement Activities 100% 15% 15 Advancing Care Information 100% 25% 25 Subtotal (Before Bonuses) 82.5 Complex Patient Bonus 3 Small Practice Bonus 0 Final Score (not to exceed 100) 85.5 2017 Press Ganey Associates, Inc. 19