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MIPS, Scoring and Submission Methods
David H. Smith, MBAHIT Project Manager
HealthInsight
Our business is redesigning health care systems for the better
HealthInsight is a private, non-profit, community based organization dedicated to improving health and health care in the
western United States.
www.healthinsight.org | Twitter: @HealthInsight_
Mountain-Pacific Quality Health
We are the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for• Montana• Wyoming• Hawaii• Alaska
• Guam• American Samoa• The Commonwealth of the
Northern Mariana Islands
Today’s Presentation
• Scoring–MIPS
• Quality• ACI• Improvement
Activities• Costs - forthcoming
• Submission–Solo–Group–Strategies for
selection–Timelines
Scoring
• Quality 60 percent• Advancing Care Information 25 percent• Improvement Activities 15 percent• Costs (0 percent of score, not required this year
2017) –Quick review on what we think is coming
The MIPS Pie
Quality 60%Advancing Care
Information 25%
Improvement Activities 15%
2017
The MIPS Pie
Quality 50%
Advancing Care Information 25%
Improvement Activities
15%
Cost 10%2018
The MIPS Pie
Quality 30%
Advancing Care Information 25%
Improvement Activities
15%
Cost 30%
2019
Sample
Category TotalPossible
Limit Actual Percent Weight Score
Quality Multiplemethods –fraction – extra points
100% 50 50% 60 30
ACI 155/100 100% 115 100% 25 25IA 40/40 or
20/20100% 20/40 50% 15 7.5
Costs 0/0
Total 62.5
MIPS – Quality Scoring
• Quality Scoring based on benchmarks, set up with deciles
• Three points for submitting each measure, up to 10/measure if in 10th decile
• See benchmarks document• Extra point for outcome/high priority
measures, in addition to six measures • Include at least one outcome measure
Deciles
Deciles – what they aren’t and what they are:• The decile could be anywhere on the spectrum
from x+0% to x-100 percent• A quality measure reporting at 45 percent is
not necessarily in the fourth decile• 45 percent could be in the third decile or the
eighth decile depending on the performance of others
Examples of Scoring Quality in MIPS
• Within 3rd decile: 3+ points toward MIPS quality• Within 1st decile: 3+ points toward MIPS quality• Within 4th decile: 4+ points toward MIPS quality• Within 5th decile: 5+ points toward MIPS quality• Within 8th decile: 8+ points toward MIPS quality• Within 2th decile: 3+ points toward MIPS quality
Example: Poor Control of A1C
Measure_NameMeasure
_IDSubmission_
MethodMeasure_
TypeBenchm
ark Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9Decile
10Topped
Out
Diabetes: Hemoglobin A1c Poor Control 1 Claims Outcome Y35.00 -25.72
25.71 -20.32
20.31 -16.23
16.22 -13.05
13.04 -10.01
10.00 -7.42
7.41 -4.01
<= 4.00 No
Diabetes: Hemoglobin A1c Poor Control 1 EHR Outcome Y54.67 -35.91
35.90 -25.63
25.62 -19.34
19.33 -14.15
14.14 -9.10
9.09 -3.34
3.33 -0.01 0 No
Diabetes: Hemoglobin A1c Poor Control 1Registry/QCD
R Outcome Y83.10 -68.19
68.18 -53.14
53.13 -40.66
40.65 -30.20
30.19 -22.74
22.73 -16.82
16.81 -10.33
<= 10.32 No
Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Claims 35.00 - 25.72
25.71 - 20.32
20.31 - 16.23
16.22 - 13.05
13.04 - 10.01
10.00 - 7.42
7.41 - 4.01
<= 4.00
No
EHR 54.67 - 35.91
35.90 - 25.63
25.62 - 19.34
19.33 - 14.15
14.14 - 9.10
9.09 - 3.34
3.33 - 0.01
0 No
Registry/QCDR 83.10 - 68.19
68.18 - 53.14
53.13 - 40.66
40.65 - 30.20
30.19 - 22.74
22.73 - 16.82
16.81 - 10.33
<= 10.32
No
1. Using Claims submitted method, how many points for 15%?
2. Using EHR method, how many points for 20%?3. Using Registry method, how many points for
15%?
Quality Scoring Scenarios
• Solo – It Depends…– Most submit six or more measures. (Claims, EHR, QCDR, QR,
Attestation) for full consideration of measures/support– Many claims based measures are topped out– Suggest evaluating benchmarks.– Consider custom QCDRs if clinically relevant, ideally, more than 20
providers submitting measures so benchmarks can be set. Also, consider where those benchmarks may be for performance reasons.
– Not all measures in each Specialty Measure Set will be applicable to all clinicians in a given specialty. If the set includes less than six applicable measures, the eligible clinician should only report the measures that are applicable.
Note Specialty Measure Sets
Note One of the Specialties w/< 6 Measures.
Equation for Scoring Quality (60% towards MIPS)
• If you’re in traditional MIPS, quality counts towards 60 percent of your total score. (lower in AAPMs where costs may also count)
Scoring Advancing Care Information
• Three components• Core • Performance• Bonus
MIPS Category: Advancing Care Information (ACI)
• 25 percent of Final Score in 2017• Promotes patient engagement and the electronic
exchange of information using certified EHR technology• Replaces the Medicare EHR Incentive Program (a.k.a.
Meaningful Use)• Greater flexibility in choosing measures• In 2017, there are two measure sets for reporting:
– ACI for those using 2015 edition CEHRT – 2017 Transition for 2014 edition CEHRT
MIPS Category: Points Possible
• Maximum Possible 155 Points. 100 will get you to the full 25 points as part of the total score for MIPS. – Base Score – 50 points– Performance – 90 points– Bonus – 15 pointsChoose to submit up to nine measures for a minimum of 90 days for additional credit.
• Bonus Credit for Public Health and Clinical Data Registry Reporting Measures
Base – 50 Points
Perform each of these with a yes/no or at least one in the numerator to demonstrate participation.
Any year 2014 or 2015 Certified Product 2017 version or for 2014 cert product users
Security Risk Analysis Security Risk Analysis
ePrescribing ePrescribing
Provide Patient Access (+ Performance) Provide Patient Access (+ Performance)
Send Summary of Care (+ Performance) Health Information Exchange (+ Performance)
Request/Accept Summary of Care Record (+ Performance)
Performance – 90 Points
Any Year 2014/2015 Certified Products 2017 – if on 2014 certified product only
Provide Patient Access 10 pts Provide Patient Access 20 pts
Send a Summary of Care 10 pts Health Information Exchange 20 pts
Request/Accept Summary of Care 10 pts View, Download, Transmit 10 pts
Patient Specific Education 10 pts Patient Specific Education 10 pts
View Download Transmit 10 pts Secure Messaging 10 points
Secure Messaging 10 pts Medication Reconciliation 10 pts
Patient Generated Health Data 10 pts Immunization registry 0 or 10 points
Clinical Information Reconciliation 10 pts
Immunization registry reporting 0 or 10 pts
Bonus – 15 Pts
Requirements for Bonus Score Requirements for Bonus Score
(report to 1 or more of the public health and clinical data registries) 5 points
(report to 1 or more of the public health and clinical data registries) 5 points
Syndromic Surveillance Registry Reporting Syndromic Surveillance Registry Reporting
Electronic Case Reporting Specialized Registry Reporting
Public Health Registry Reporting Clinical Data Registry Reporting
10 points options below 10 points options below
Report certain improvement activities Report certain improvement activities
Advancing Care Information Calculator.xlsx
Improvement Activity Scoring
• 40 Points for groups > 15 providers• 20 Points required for groups < 15 providers
• High 20 Points• Medium 10 Points
Scenarios
• Larger groups will typically have several improvement activities happening in their system.
• Finding improvement activities that are supported by 1+ providers give credit to the whole group
Full Support for Improvement Activities
• Patient Centered Medical Home (PCMH)• State-based PCMH (if approved like Oregon’s
PCPCH)
Sample
Category TotalPossible
Limit Actual Percent Weight Score
Quality Multiplemethods –fraction – extra points
100% 50 50% 60 30
ACI 155/100 100% 115 100% 25 25IA 40/40 or
20/20100% 20/40 50% 15 7.5
Costs 0/0
Total 62.5
Submission Methods
NEXT TOPIC – Submission Methods• Group and Solo submission options• Your TIN may be choosing a method for you• If working in multiple TINs, or if you have your own
clinic aside from employment, you may need to report for each TIN
• Providers moving from other TINs may utilize reporting from other domains
Submission Methods
EHR QualifiedRegistry
QCDR Attestation
WebInterface(June 30 –groups only)
CAHPS(June 30 groups only, counts as 1)
Claims
Quality X X X X X X
Advancing Care Info.
X X X X X
ImprovementActivities
X X X X X
Costs X
Group Providers
• CMS Web Interface (only available to groups with 25 or more eligible clinicians)
• Qualified Clinical Data Registry (QCDR)• Qualified Registry• Electronic Health Record (EHR)• CAHPS for MIPS Survey (only available to groups with
2 or more eligible clinicians)• Attestation – ACI and IA only (not quality)
Submission Methods
EHR QualifiedRegistry
QCDR Attestation
WebInterface(June 30)
CAHPS(June 30 groups only)
Claims
Quality X X X X X X
Advancing Care Info.
X X X X X
ImprovementActivities
X X X X X
Costs X
Strategies for Selection
• You can only use one submission method per category in 2017
• Possibly changing to multiple methods per category in future years per 11 days old proposed rule on 2018 MIPS
Timelines
• June 30, three days from now• Deadline for Web Interface• Deadline for CAHPS
QCDR
Quality ACI Improvement Activity
If using custom or registry measures, confirm that enough providers will report
Confirm your chosen QCDR/ssupport this, or arrange for optional method of submission.
Confirm your chosen QCDR/ssupport this, or arrange for optional method of submission.
Confirm that benchmarks are or will be available.Evaluate value of submitting more measures to your organization and to your specialty area.
https://qpp.cms.gov/docs/QPP_2017_CMS_Approved_QCDRs.pdf
QCDR Suggestions
• Measures submitted may not be “official” MIPS measures but can count.
• Suggestions:– Consider appropriateness to your specialty– You may get a score higher than 3 for your performance
within deciled averages if others submit (over 20), suggest confirming with vendor
– Suggest confirming average reporting rates will be available
Qualified Registry – Solo
https://qpp.cms.gov/docs/QPP_MIPS_2017_Qualified_Registries.pdf
Quality ACI Improvement ActivityIf using custom or registry measures, confirm that enough providers will report
Confirm your chosen QR/ssupport this, or arrange for optional method of submission.
Confirm your chosen QR/ssupport this, or arrange for optional method of submission.
Confirm that benchmarks are or will be available.Evaluate value of submitting more measures to your organization and to your specialty area.
Qualified Registry Suggestions
• Measures are on the list w/information regarding benchmarks
• Consider if benchmarks exist• Consider using measures that support state-based
initiatives if you are in primary care for 2/1 reporting benefit– Example: SBIRT, or alcohol and substance abuse measures
have applicability to state based reports in places like Oregon
Electronic Health Record
• Advantages of using EHR vendor to submit– EHR real time knowledge of where your measures are at, possibly
daily, or at least monthly or quarterly in most cases– Up to date information
• Some vendors may share in mutual benefits of improving quality
• Consider measures submission benefits to performance rankings in benchmarks. Some methods of submission are easier to achieve
Quality ACI Improvement ActivityEvaluate measures Obvious benefits to utilizing
ACI for EHR submission. Improvement Activities may be more difficult to prove, confirm.
Administrative Claims
Quality ACI Improvement ActivityClaims data can be difficult to confirm for many quality measures, and more difficult to compete in with standard measures.
Not applicable. N/A
Attestation
Quality ACI Improvement ActivityN/A Consider probability of
errorConsider data validation to support improvement activities if audited
Helpful if one more than one EHR
Web Interface
Quality ACI Improvement Activity15 measures Vendor submission
optionsAbility to support improvement activities using this method.
Upcoming Webinar Series
•Improving Your ScoreJuly 11
All sessions will be held at 1-2 p.m. MTRegister at www.healthinsight.org/qpp
Questions
This material was prepared by HealthInsight, the Medicare Quality Innovation Network-Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-D1-17-40
How to Ask a Question
For More Information Contact a QPP Expert in Your State
Mountain-Pacific Quality Health
Please contact us for assistance!
MontanaAmber [email protected](406) 544-0817
WyomingBrandi [email protected](307) 472-0507
Hawaii and TerritoriesCathy [email protected](808) 545-2550
AlaskaPreston [email protected](907) 561-3202
Region/Senior Account ManagerSharon [email protected](307) 271-1913
Visit us online at www.mpqhf.org.
For More Information Contact a QPP Expert in Your State HealthInsight QPP Support
Call: 801-892-6623Email: [email protected]
Web: www.healthinsight.org/qpp
NevadaAaron HubbardCall: 702-948-0306Email: [email protected]
OregonDavid Smith Call: 503-382-2962Email: [email protected]
Utah Brock StonerCall: 801-892-6602Email: [email protected]
New Mexico Ryan Harmon or Danielle PickettCall: 505-998-9752 or 505-998-9768Email: [email protected] [email protected]