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PHA/KPP Kettering Health Network:
“A Deep Dive on the Quality Category of MIPS”
Dr. Troy Tyner, D.O.
April 6,2017
2Value Driven. Health Care. Solutions.
Goals for Session
• CMS Grant Update for PHA Members
• Overview of our PHA/KPP goals
• Ensure You Pay NO Penalties
• Overview of MIPS
• Update on MIPS and Data Submission
• Ensure you know your practice scores
• Ensure You Pay NO Penalties
PHA CMS Grant Status
3Value Driven. Health Care. Solutions.
Clinicians: 496 involved
Successes:
• 300 site interactions in Q1 2017 with practices
• Practices made strong progress
• Several practices that would have failed to submit PQRS in
2016 were able to successfully meet requirements.
• All practices have taken the minimum required steps to avoid
the MIPS penalty.
• Opportunities:
• Practices using Epic Ambulatory EHR report difficulty getting
quality reports, determining reportable measures, and
access to understanding Epic reporting requirements and
capabilities.
PCP Phase Scores
Phase 1 (Action Plan)
• Set Aims – 23
• Phase 2
• Use Data to Drive Care – 106
• Phase 3
• Achieve Progress on Aims – 19
Phase 4
• Achieve Benchmark Status – 0
Phase 5
• Thrive as a Business in Pay-for-Value Approached – 0
PHA/KPP 2017 Goal
Drive 100% that desire
to Phase 3
Specialist Phase Scores from PAT
Phase 1 (Action Plan)
• Set Aims – 51
Phase 2
• Use Data to Drive Care – 413
Phase 3
• Achieve Progress on Aims – 3
Phase 4
• Achieve Benchmark Status – 0
Phase 5
• Thrive as a Business in Pay-for-Value Approached – 0
PHA/KPP 2017 Goal
Drive 100% that desire
to Phase 3
Medical Advantage Group
Experienced team brings years of
success and knowledge in areas that
align with the requirements of MIPS
Medical Advantage Group’s
experience has resulted in:
– 196,445 gaps closed from end of 2014
to Nov. 2016. From 45% to 69% in
gaps closured.
– 176 PCMH practices
– Increased PMPM earning to our
physicians. In 1 contract alone,
increase of $9.15 PMPM in 2 years.
– PCPs earned > $1,900,000 and
specialists earned $1,800,000 in
value-based incentive payments
6Value Driven. Health Care. Solutions.
$5.36
$11.80
$14.51
$0.00$1.00$2.00$3.00$4.00$5.00$6.00$7.00$8.00$9.00
$10.00$11.00$12.00$13.00$14.00$15.00$16.00$17.00$18.00
Total 2014 Total 2015 Total 2016
CIPA PGIP INCENTIVE/ADMINISTRATIVE
PAYMENTS TO PHYSICIANS AND
Deep Dive into MIPS
Beth Hickerson and Angela Hale
Quality Improvement Advisors
PHA Physicians
April 6, 2017
Value Driven. Health Care. Solutions.
Medicare Access and CHIP Reauthorization Act of 2015
(MACRA)
9Value Driven. Health Care. Solutions.
Supported by organized medicine
– Repealed the Sustainable Growth
Rate (SGR) methodology
– Passed with over 90 percent
support in both the House and
Senate; bi-partisan legislation
Created Quality Payment
Program which moves Medicare
into value-based payments
Quality Payment Program (QPP)
January 1, 2019 – physicians enter the APM track or the MIPS track
For the first few years, majority of clinicians in MIPS
10Value Driven. Health Care. Solutions.
Quality Payment Program
(QPP)
Merit-based Incentive
Payment System (MIPS)
Alternative Payment Model
(APM)
Advanced APM MIPS APM
MIPS Payment Adjustments
Final score of 0-100
calculated for each eligible
clinician/group based on
performance in four categories
Final score compared against
threshold to determine
payment adjustment to MPFS
First MIPS performance year-
2017
First MIPS payment year-2019
12Value Driven. Health Care. Solutions.
Threshold
4x% 5x% 7x% 9x%
-4x% -5x% -7x% -9x%
2019 2020 2021 2022
Example of MIPS Negative Adjustment
13Value Driven. Health Care. Solutions.
MPFS
Reimbursement
2017 data/
2019 payment
2018 data/
2020 payment
2019 data/ 2021
payment
2020 data/
2022 payment
Maximum Loss 4% 5% 7% 9%
$50,000 $2,000 $2,500 $3,500 $4,500
$100,000 $4,000 $5,000 $7,000 $9,000
$400,000 $16,000 $20,000 $28,000 $36,000
Example of MIPS Positive Adjustment
14
MPFS
Reimbursement
2017 data/
2019 payment
2018 data/
2020 payment
2019 data/
2021 payment
2020 data/
2022 payment
Plus or Minus 4% 5% 7% 9%
Bonus 10% 10% 10% 10% 10%
$50,000 $7,000 $7,500 $8,500 $9,500
$100,000 $14,000 $15,000 $17,000 $19,000
$400,000 $56,000 $60,000 $68,000 $76,000
Value Driven. Health Care. Solutions.
MIPS Final Score for 2017 Performance Year
15Value Driven. Health Care. Solutions.
Final Score Payment Adjustment
≥70 points – Positive adjustment
– Eligible for exceptional performance bonus – minimum of
additional 0.5%
4-69 points – 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
MIPS Category Weights Over Time
:
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Quality
Advancing Care
Information
Improvement
Activities Cost
Replaces PQRS Replaces MU New (PCMH) Replaces VBM
2017 60% 25% 15% 0%
2018 50% 25% 15% 10%
2019+ 30% 25% 15% 30%
MIPS Eligible Providers
Years 1 and 2 Medicare Part
B clinicians:
Physicians MD, DO
Podiatrists
Optometrists
Chiropractors
Dentists
Physician Assistants
Nurse Practitioners
Clinical Nurse Specialists
Certified Registered Nurse
Anesthetists
Year 3+ Medicare Part B
clinicians:
Occupational Therapists
Physical Therapists
Speech Therapists
Audiologists
Nurse Midwives
Clinical Social Workers
Dietitians
17Value Driven. Health Care. Solutions.
MIPS Exempt Providers
3 groups of clinicians:
18Value Driven. Health Care. Solutions.
First year of
Medicare Part B
participation
Below low patient
volume threshold
Certain
participants in
ADVANCED
Alternative
Payment Models100 or fewer Part B patients
OR billing no more than
$30k/year
NOTE: MIPS does not apply to hospitals or facilities
Pick Your Pace Options
Three options to participate in MIPS in 2017:
19Value Driven. Health Care. Solutions.
Don’t submit
Three Ways to Avoid the Penalty in 2017
20Value Driven. Health Care. Solutions.
1Quality
Measure
1Improvement
Activity
5Required Advancing Care
Information
Measures
OR OR
Physician Compare Website
Shows MIPS composite
scores and individual
performance category
scores
Patients can see health
care providers rated on a
scale of 0 to 100 and
how physician compares
to peers nationally
21Value Driven. Health Care. Solutions.
Reporting Options
Individual – defined as a single NPI tied to a single TIN
– May protect incentive potential for high-performing
providers
– May be easier if you have NPIs not required to report
Group – multiple NPIs that share a common TIN
– May ease administrative burden
– Beneficial if you have some providers with reporting
obstacles
– Register only if using CMS web interface or CAHPS for
MIPS
Note: Reporting option applies for all four categories; NPIs must report for
each TIN separately
23Value Driven. Health Care. Solutions.
Reporting Methods
Claims
EHR
Registry
Qualified Clinical Data Registry
CMS Web Interface
CAHPS for MIPS Survey
Note: You may only report via one method per category
24Value Driven. Health Care. Solutions.
Reporting Methods (cont.)
Claims
– Add modifier codes to your Medicare claims
– Can be added manually by billers or automatically by
EHR or billing software
EHR
– Directly submit a QRDA III file through the CMS portal
– Register with your EHR to submit on your behalf
as/through a Data Submission Vendor (DSV)
– This category does not include EHRs who submit via
registry
25Value Driven. Health Care. Solutions.
Reporting Methods (cont.)
Registry
– Entity that collects data and submits to CMS
– Clinical data can be extracted from EHR or manually
entered via registry web form
– Claims data can be submitted via registry
Qualified Clinical Data Registry (QCDR)
– CMS-approved entity that collects medical and/or clinical
data for the purpose of patient disease tracking to foster
improvement in quality of care
– Usually includes specialty measures not on the general
MIPS measures list
– Clinical data can be extracted from EHR or manually
entered
26Value Driven. Health Care. Solutions.
Reporting Methods (cont.)
CMS Web Interface (GPRO)
– Groups of 25 or more
– Populate data (manually or electronically) and report all
GPRO measures on 248 identified attributed patients
– Must register by June 30, 2017
CAHPS for MIPS
– Survey of patients administered and submitted by
approved vendor
– Counts as one of six required measures
– Must submit remaining five measures via other method
– Earn extra bonus points
27Value Driven. Health Care. Solutions.
Data Completeness Rule
Claims – 50% of all Medicare Part B patients
EHR, Registry, QCDR – 50% of all patients
GPRO – all patients assigned, up to 248
28Value Driven. Health Care. Solutions.
Quality Reporting Requirements
Report six measures, including
at least one outcome or high
priority measure
Select from full list of 291
MIPS measures
Or select from a set of
specialty specific measures
31Value Driven. Health Care. Solutions.
3-10 points per measure
based on performance
against a benchmark
60 possible points
Bonus points for high-priority
and EHR reporting
60Points
Measure Choices
32Value Driven. Health Care. Solutions.
https://qpp.cms.gov/measures/quality
Selecting Measures
1. Decide on your reporting method – Claims, EHR,
Registry, QCDR
– Reporting via EHR is easiest but may limit choice of
measures
2. Compile list of all available measures for your chosen
method
3. Narrow your list to include only applicable measures
– Specialty/scope of practice
– Patient population
– Data collection limitations
33Value Driven. Health Care. Solutions.
Selecting Measures (cont.)
4. Calculate your estimated MIPS points per measure
https://qpp.cms.gov/resources/education
“2017 Quality Benchmarks”
34Value Driven. Health Care. Solutions.
Measure_NameSubmission
MethodDecile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10
Pneumonia Vaccination
Status for Older AdultsClaims
39.78 -
51.32
51.33 -
61.67
61.68 -
70.47
70.48 -
77.77
77.78 -
84.49
84.50 -
91.99
92.00 -
99.06>= 99.07
Pneumonia Vaccination
Status for Older AdultsEHR
14.13 -
23.25
23.26 -
33.02
33.03 -
43.58
43.59 -
53.96
53.97 -
63.60
63.61 -
74.54
74.55 -
85.52>= 85.53
Pneumonia Vaccination
Status for Older AdultsRegistry/QCDR
12.24 -
24.02
24.03 -
36.34
36.35 -
48.51
48.52 -
58.95
58.96 -
68.05
68.06 -
77.77
77.78 -
90.19>= 90.20
Quality Scoring Basics
Each measure earns between 3 to 10 points
Minimum 20 cases for a measure to earn performance
points above the minimum
Some measures may have a maximum < 10
Reporting additional outcome and high priority
measures yields bonus points
Measures reported via “electronic end-to-end” method
earn 1 bonus point
35Value Driven. Health Care. Solutions.
Quality Scoring Tips
If you submit > six measures, CMS will use the highest
scoring six for your base score
Measures submitted but not scored are still eligible for
bonus points
Groups with 16 or more providers and 200+ eligible
cases will have All-Cause Hospital Readmission
36Value Driven. Health Care. Solutions.
ACI Basics
39Value Driven. Health Care. Solutions.
– Security risk analysis
– e-Prescribing
– Provide patient access
– Send summary of care
– Request/accept summary of
care
– 5 percent per measure
for public health/clinical
data registry reporting
– 10 percent for
improvement activity
alignment
– Submit nine measures
for 90 days for
performance credit
Required base
score (50)
Performance
score (up to 90)
Bonus score
(up to 15)
50 90 15
Choosing Your Objectives/Measures List
https://qpp.cms.gov/measures/aci
40Value Driven. Health Care. Solutions.
2017 Transition Objectives and Measures
Core
1. Security Risk Analysis
2. e-Prescribing
3. Provide Patient Access
4. Health Information
Exchange
Performance
1. Provide Patient Access
2. Health Information
Exchange
3. View, Download, or
Transmit (VDT)
4. Patient-Specific Education
5. Secure Messaging
6. Medication Reconciliation
7. Immunization Registry
Reporting
41Value Driven. Health Care. Solutions.
Performance Measure Scoring
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Performance Rates for Each Measure
1-10% = 1
11-20% = 2
21-30% = 3
31-40% = 4
41-50% = 5
51-60% = 6
61-70% = 7
71-80% = 8
81-90% = 9
91-100% = 10
ACI Scoring Tips
Start improving your performance measure scores
above previous MU thresholds
– Provide Patient Access
– Health Information Exchange
– Patient Specific Education
– Medication Reconciliation
Consider implementing an Improvement Activity using
your EHR to get 10 bonus points
Consider reporting to a specialized registry or public
health department for 5% bonus
44Value Driven. Health Care. Solutions.
Improvement Activities Basics
Attest to completing up to four
activities at least 90 days
during the year
Rural, health professional
shortage area (HPSA), or
group practices with 15 or
fewer clinicians attest to only
two activities
Eligible clinicians choose from
92 activities in nine categories
46Value Driven. Health Care. Solutions.
1. Expanded
Practice
Access
2. Population
Management
3. Care
Coordination
4. Beneficiary
Engagement
5. Patient
Safety and
Practice
Assessment
6. Participation
in an APM
7. Achieving
Health Equity
8. Integrating
Behavioral and
Mental Health
9. Emergency
Preparedness
and Response
Examples of Improvement Activities
47Value Driven. Health Care. Solutions.
After hours
access to care
Same day
appointments
Extended
office hours
Test tracking
system
Improvement Activities Scoring
40 points needed to maximize this category
Medium-weighted activities worth 10 points
High-weighted activities worth 20 points
Points doubled for rural, HPSA, or small group
practices (15 or fewer providers)
Full credit for clinicians in CPC+, in a PCMH, or in
similar specialist practice
– PCMH certifications for MIPS include: a national program,
a regional or state program, a private payer, or other body
that certifies at least 500 practices
Participation in Transforming Clinical Practice Initiative
is a high-weighted activity
48Value Driven. Health Care. Solutions.
Selecting Improvement Activities
https://qpp.cms.gov/measures/ia
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Cost Basics
In 2017, cost does not impact MIPS score
Clinicians are not required to submit cost data to CMS
– CMS assesses clinicians based on Medicare claims data
CMS compares resources used to treat similar care
episodes and clinical condition groups across practices
Cost measures adjusted for geographic payment rates
and beneficiary risk factors
Find previous cost information for your practice in your
2015 Annual Quality Resource and Use Report
(QRUR)
51Value Driven. Health Care. Solutions.
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