MACRA, MIPS, AND QCDRUPDATES ON MSSIC REPORTING OPTIONS

David R. Nerenz, Ph.D.

Time Line

• November 2016 – Agree to pursue QCDR status for MSSIC registry (done)

• January 2017 – apply for QCDR status (done)

• May 2017 – CMS approval (done)

• June 2017 – CMS approval of measures (done)

• Rest of 2017 – work with ArborMetrix on specifications for data submission

• Rest of 2017 – work with groups planning to use MSSIC as QCDR on measure selections

• First quarter of 2018 – report data for 2017

Approved* Measures for MIPS Reporting from MSSIC

• Pre-surgical screening for depression• Assessment of back or neck pain• Assessment of leg or arm pain• Assessment of pain-related disability

(ODI/NDI)• Follow-up (90 day) assessment of

myelopathy (cervical only)• Percent same-day ambulation• Rate of VTE Prophylaxis• Rate of use of Pre-op skin

preparation/wash

• Percent of patients achieving MCID for back or neck pain

• Percent of patients achieving MCID for leg or arm pain

• Percent of patients achieving MCID for pain-related disability (ODI/NDI)

• Percent Satisfied with Result• Risk-adjusted rate of hospital readmission• Risk-adjusted rate of surgical site infection• Risk-adjusted rate of urinary retention• Unplanned Return to OR Rate

*A few measures are provisionally or conditionally approved, with use for 2018 conditional onCMS review and approval of data submitted for 2017.

Other Details

• Can report stratified data (e.g., only for lumbar fusions, or only for cervical decompressions)

• Will report risk-adjusted data (need to develop and discuss models for variables for which models do not exist)

Next Steps

• Now through mid-September – Obtain indications of interest from surgeons and surgeon groups (not binding)

• Fall of 2017 - Work with ArborMetrix to do test submissions to CMS and work with surgeons and groups to check accuracy of data and to choose measures for submission

• Fall of 2017 - Work with interested surgeons to assure that minimum standards for data completeness are met (CMS 50% rule)