Maximizing Performance in MIPS!
Beth HickersonLead Quality Improvement Advisor
August 14, 2017
Value Driven. Health Care. Solutions.
MACRA Jumpstart – Maximizing Performance in MIPS!
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At the close of our presentation you should have a better idea of how to improve accuracy and performance in your reporting and documentation for MIPS. We will also share free CMS Resources for MIPS support:
– QPP Resource Center– www.qppresourcecenter.com
– Medical Advantage Group’s MACRA Jumpstart– www.medicaladvantagegroup.com/macra
jumpstart/– [email protected]
Need to Catch Up?
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If today is your first webinar with us and you need to catch up, visit our MACRA Jumpstart Website: – www.medicaladvantagegroup.com
/macrajumpstart/
We have a library of past MACRA Jumpstart Webinars, and many other resources to help you get off to a successful start:– June 21 – Using Free CMS
Resources for MIPS Success– July 12 – Preparing Your Small
Practice for MIPS Success
REVIEW OF MIPS SCORING
Quality
Quality Overview
RequirementsReport 6 measuresInclude at least 1 outcome or high priority measureChoose from 291 generally approved MIPS measures
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Scoring60 possible category points3-10 points per measure based on performance against a benchmark Up to 12 bonus points available
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Understanding Benchmarks
Benchmark – standard based on historical data2017 Quality benchmarks set from 2015 PQRS data– Mean/Average determined– Performance scores distributed along a decile range
Download “2017 Quality Benchmarks" at https://qpp.cms.gov/about/resource-library
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Measure Name Submission Method Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10
Pneumonia Vaccination Status for Older Adults Claims 39.78 -
51.3251.33 -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 Adults EHR 14.13 -
23.2523.26 -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 Adults Registry/QCDR 12.24 -
24.0224.03 -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 Category Bonus Points
Additional High-priority or Outcome measures – High-priority = 1 point per measure– Outcome = 2 points per measure– Up to 6 points maximum
“End-to-End” Electronic reporting – From point of service through to CMS– EHR– Registry or QCDR if data extracted and submitted to
CMS electronically– 1 point per measure, up to 6 points maximum
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Quality Category Score
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Each measure
earns 3-10 points
End-to-End
bonus points
High-priority
and Outcome
bonus points
TOTAL POINTS EARNED
REVIEW OF MIPS SCORING
Advancing Care Information
ACI Overview
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– Security risk analysis– e-Prescribing– Provide patient access– Send summary of care
– 5 percent per measure for public health/clinical data registry reporting
– 10 percent for improvement activity alignment
– Submit 7 measures for 90 points for performance credit
Required base score (50)
Performance score (up to 90)
Bonus score (up to 15)
50 90 15
2017 Transition Objectives and Measures
Core (Required)50 Points1. Security Risk Analysis2. e-Prescribing3. Provide Patient Access4. Health Information
Exchange
Performance (Optional)Up to 90 Points1. Provide Patient Access*2. Health Information*
Exchange3. View, Download, or
Transmit (VDT)4. Patient-Specific Education5. Secure Messaging6. Medication Reconciliation7. Immunization Registry
Reporting
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*Performance points doubled on these measures
Performance Measure Scoring
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Performance Rates for Each Measure
1-10% = 111-20% = 221-30% = 331-40% = 441-50% = 5
51-60% = 661-70% = 771-80% = 881-90% = 9
91-100% = 10
Advancing Care Information Bonus Points
Public Health or Clinical Data Registry Reporting– 5 points – Includes Syndromic Surveillance, Cancer Registry,
QCDRs, etc.
CEHRT-related Improvement Activity– 10 points– See list under Appendix B of “Advancing Care
Information Performance Category Fact Sheet” at https://qpp.cms.gov/docs/QPP_ACI_Fact_Sheet.pdf
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Advancing Care Information Category Score
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Base Points
(50)
Performance Points
(up to 90)
Bonus Points
(up to 15)
TOTAL POINTS EARNED
STRATEGY #1
Maximize Bonus Points
Quality Category Bonus Points
Check with your EHR or registry to see if you qualify for “end-to-end” electronic reporting pointsReport on additional high-priority and outcome points– Report more than 6 measures overall– Report as many measures as possible to achieve maximum 6
points– Report even if performance is low – Additional measures must have at least 20 patients in the
denominator and 1 patient in the numerator to qualify
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Advancing Care Information Bonus Points
Research QCDRs and/or Specialized Registries applicable for your specialty– Consider cost and time required to meet this
requirementReview the CEHRT-related Improvement Activities for activities you are already doing or could easily do– Start activity by October 2nd for full 90 day period– See Appendix B of “Advancing Care Information
Performance Category Fact Sheet” at https://qpp.cms.gov/docs/QPP_ACI_Fact_Sheet.pdf
– Download “MIPS Data Validation Criteria” at https://qpp.cms.gov/about/resource-library
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STRATEGY #2
Understand Measure Specifications
Review Your Measure Specifications
Measure specs include – Numerator and denominator details– Exclusion and Exception criteria – Measure Rationale (Quality)– Additional Information (ACI)Quality Measure Specs for Claims and Registryhttps://qpp.cms.gov/docs/QPP_quality_measure_specifications.zip
eCQM Measure Specshttps://ecqi.healthit.gov/eligible-professional-eligible-clinician-ecqms
ACI Measure Specshttps://qpp.cms.gov/docs/QPP_Advancing_Care_Information_Measure_Specifications.zip
Claims and Registry Specs
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eCQM Specs
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Note: Scroll down and click on the .html file under Specifications for full details
Advancing Care Information Specs
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STRATEGY #3
Align Documentation Workflows
Defining “Align Documentation Workflows”
Entering data in the specific EHR field where it is tracked for your Quality and ACI measuresCommon data tracking areas:– Modules (Vitals, Medication, Immunization, Family
History, Social History)– Health Maintenance Record– Lab results– Smart templates in visit notesMeasures will always track via discrete data fields, never text fields or scanned documents
Documentation Red Flags
Performance rates don’t make sensePerformance rates of 0% or 100%Performance rates vary widely from benchmarksPerformance rates vary significantly between practice providers
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Steps for Aligning Workflows in EHR
1. Request a copy of updated workflow instructions from your EHR– May be called “whitepapers”– May be found via support link in EHR– May be updated annually
2. Review the workflow instructions with your most knowledgeable provider AND clinical staff member– Do instructions match real-life habits?
3. Train staff and providers on new workflows– If many to correct, train one or two at a time
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Steps for Aligning Workflows in EHR (cont.)
4. Print baseline Quality and ACI reports– Take note of the data that new workflows were
implemented– You should see improvement within 1-3 months
5. Share measure data with staff and providers to highlight errors and improvement– They can’t argue with data!
6. Track quality measures on a monthly basis– Notify your EHR vendor immediately if you notice
inconsistencies
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Aligning Workflows with a Registry
Understand how your data is mapped electronically– Measures may be tracked differently in your registry than
in your EHRReview registry reports monthly – If reporting MIPS via registry, your registry reports trump
your EHR reportsBe prepared for mapping errors when your EHR is updated
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STRATEGY #4
Alter Clinical Workflows
Tips for Improving Performance
Involve your staff– Informal or formalDon’t reinvent the wheel– Look for “bright spots” and identify repeatable habits– Share ideas with a peer practice– Search the web for improvement ideasTest change before implementation– Avoid unnecessary confusion– Demonstrate success to create buy-inFocus on highest impact measures– Check benchmark deciles
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Tips for Improving Performance (cont.)
Focus on highest impact measures– Topped out?– Check benchmark deciles
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Measure_Name Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10 Topped Out
Pneumonia Vaccination Status for Older Adults
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 No
Diabetes: Eye Exam69.39 -89.68
89.69 -95.95
95.96 -98.72
98.73 -99.99 -- -- -- 100 Yes
Questions?
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Next Webinar – Sept. 6
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Visit Medical Advantage Group’s MACRA Jumpstart Page:– www.medicaladvantagegroup.com/mac
rajumpstart/
Register for our Sept. 6 webinar: – MACRA Jumpstart: MIPS Quality
Category 101 – This will be a primer on reporting quality
measures
View our other upcoming webinars:– Oct. 12 – MIPS Advancing Care
Information 101– Nov. 9 – QPP Final Rule for 2018
Beth [email protected]
Value Driven. Health Care. Solutions.