Learning Forum Fridays Countdown to MIPS Data Submission Webinar Series Improvement Activities: What You Have To Do Merit-based Incentive Payment System = MIPS Liem Tran Health Informatics Specialist Health Services Advisory Group (HSAG) October 6, 2017
Disclosure I have nothing to report, nor are there any real or perceived conflicts of interest, implied or expressed, in the following presentation. Liem Tran, Health Informatics Specialist 2
Agenda Overview of MIPS reporting What are Improvement Activities (IAs)? How to score IAs? How to select IAs? Program resources 3
Overview of MIPS Reporting What Do I Need To Know?
What Are the Performance Category Weights? Weights assigned to each category is based on a 1 to 100 point scale. Transition Year Weights Quality Cost Improvement Advancing Care Information 60% 0% Activities 15% 25% Note: These are defaults weights; the weights can be adjusted in certain circumstances. 5
What are IAs?
MIPS Performance Category: IAs Assess how much you participate in activities that improve clinical practice. Choose from 90+ activities under 8 subcategories: 1. Expanded Practice Access 2. Population Management 3. Care Coordination 4. Beneficiary Engagement 5. Patient Safety and Practice Assessment 6. Achieving Health Equity 7. Integrating Behavioral and Mental Health 8. Emergency Preparedness and Response Source: The Centers for Medicare & Medicaid Services 7
How to View List of IAs How do I do this? Go to qpp.cms.gov. Click on the tab at the top of the page. Select the performance category of interest. 8 Source: The Centers for Medicare & Medicaid Services
How are IAs Scored?
MIPS Performance Category: IA Requirements for the Transition Year Requirements for the Transition Year: Submit Something Submit a Partial Year +% Submit a Full Year Test Means Submitting 1 Improvement Activity for 90 days Partial Means Submitting data on all MIPS categories for at least 90 days Full Means Submitting data on all MIPS categories for the entire year 10 Source: The Centers for Medicare & Medicaid Services
MIPS Scoring for IAs (15 Percent of Final Score in Transition Year) Maximum points = 40 Medium High Large Practice (15 or more) 10 20 For clinicians in small (fewer than 15 participants), designated rural area, and Designated HPSA practices; and non-patient facing MIPS-eligible clinicians or groups 20 40 Full credit (40 points) for clinicians in a patient-centered medical home, Medical Home Model, or similar specialty practice HPSA = Health Professional Shortage Area 11 Source: The Centers for Medicare & Medicaid Services
MIPS Performance Category: IA Special Consideration For 15 or fewer participants, nonpatient-facing clinicians, or if you are in a rural or health professional shortage area: Attest that you completed up to 2 activities for a minimum of 90 days. Participants in certified patientcentered medical homes, comparable specialty practices, or an Alternative Payment Model (APM) designated as a Medical Home Model: You will automatically earn full credit. Participants in certain APMs, such as Shared Savings Program Track 1 or the Oncology Care Model: You will automatically receive points based on the requirements of participating in the APM. For all current APMs under the APM scoring standard, this assigned score will be full credit. For all future APMs under the APM scoring standard, the assigned score will be at least half credit. 12 Source: The Centers for Medicare & Medicaid Services
MIPS Performance Category: IAs Eligible for ACI Bonus 10% ACI Bonus For using CEHRT to report certain IAs : IA Performance Category Subcategory Activity Name Weight Expanded Access Practice Provide 24/7 access to eligible clinicians or groups who have real-time access to High patient s medical record Population Management Anticoagulant management improvements High Population Management Glycemic management services High Population Management Chronic care and preventive care management for empaneled patients Medium Population Management Implementation of methodologies for improvements in longitudinal care Medium management for high risk patients Population Management Implementation of episodic care management practice improvements Medium Population Management Implementation of medication management practice improvements Medium Care Coordination Implementation of use of specialist reports back to referring clinician or group Medium to close referral loop Care Coordination Implementation of documentation improvements for practice/process Medium improvements Care Coordination Implementation of practices/processes for developing regular individual care plans Medium Care Coordination Practice improvements for bilateral exchange of patient information Medium Beneficiary Engagement Use of certified EHR to capture patient reported outcomes Medium Beneficiary Engagement Engagement of patients through implementation of improvements in patient Medium portal Beneficiary Engagement Engagement of patients, family, and caregivers in developing a plan of care Medium Patient Safety and Practice Assessment Use of decision support and standardized treatment protocols Medium Achieving Health Equity Leveraging a QCDR to standardize processes for screening Medium Integrated Behavioral and Mental Health Implementation of integrated primary care behavioral health (PCBH) model High Integrated Behavioral and Mental Health EHR Enhancements for behavioral health (BH) data capture Medium 13 Source: The Centers for Medicare & Medicaid Services
How to Select IAs?
Choose Your Measures/Activities: Tips Tips for reviewing and selecting measures/activities; Consider the following: Your patient population and the clinical conditions that you treat Your practice location Your practice improvement goals Your current workflow and activities you may already be doing Your Independent Practice Association (IPA) and health plan requirements 15 Source: The Centers for Medicare & Medicaid Services
Example IAs
Example 1: Provide 24/7 Access to Eligible Clinicians or Groups to Patient Record Activity Weighting: High Category: Expanded Practice Access Description: Provide 24/7 access for advice about urgent and emergent care Expanded hours in evenings and weekends with access to the patient medical record Use of alternatives to increase access to care, such as e-visits, phone visits, group visits, home visits, and alternate locations Provision of same-day or next-day access when needed for urgent care or transition management 17
Example 1: Provide 24/7 Access to Eligible Clinicians or Groups to Patient Record (cont.) Suggested documentation: Patient Record from electronic medical record (EHR) A patient record from a certified EHR with date and timestamp indicating services provided outside of normal business hours for that clinician; or Patient Encounter/Medical Record/Claim Patient encounter/medical record claims indicating patient was seen or services provided outside of normal business hours for that clinician including use of alternative visits; or Same or Next Day Patient Encounter/Medical Record/Claim - Patient encounter/medical record claims indicating patient was seen sameday or next-day to a consistent clinician for urgent or transitional care 18
Example 2: Tobacco Use Activity Weighting: Medium Category: Behavioral and Mental Health Description: Regular engagement in integrated prevention and treatment interventions Tobacco use screening and cessation interventions for patients with co-occurring conditions of behavioral and mental health At risk factors for tobacco dependence 19
Example 2: Tobacco Use (cont.) Suggested documentation: Patient Reported Outcomes in EHR Report from the certified EHR or the patient activation measures performed Separate Queue for Recognition and Review Documentation showing the call out of this data for clinician recognition and review (e.g. within a report or a screen-shot) 20
Example 3: Implementation of Antibiotic Stewardship Program Activity Weighting: Medium Category: Patient Safety and Practice Assessment Description: Implementation of an antibiotic stewardship program Measures the appropriate use of antibiotics for several different conditions 21
Example 3: Implementation of Antibiotic Stewardship Program (cont.) Suggested documentation: Documentation of implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions according to clinical guidelines for diagnostics and therapeutics and identifies improvement actions 22
Program Resources
Program Resources (cont.) CMS QPP website: https://qpp.cms.gov/mips/improvement-activities IAs specification: https://qpp.cms.gov/docs/qpp_quality_measure_ specifications.zip HSAG QPP Service Center website: https://www.hsag.com/qpp 24
Questions 25
Thank you! Liem Tran, B.S. Health Informatics Specialist 818.653.3898 ltran@hsag.com
This material was adapted 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, based on original content from CMS. The contents presented do not necessarily reflect CMS policy. Publication No. QN-11SOW-D.1-09262017-01