Strategies for Achieving High Scores in MIPS Performance Categories Padma Taggarse, MMI, MBA Executive Director, Physician Office Quality Kari Vanderslice, MBA, PCMH, CCE Health Informatics Specialist Health Services Advisory Group (HSAG) September 29, 2017 MIPS = Merit-Based Incentive Payment System

Disclosure I have nothing to report, nor are there any real or perceived conflicts of interest, implied or expressed, in the following presentation. Padma Taggarse, MMI, MBA Kari Vanderslice, MBA, PCMH, CCE

Agenda Welcome Overview of MIPS scoring Performance measure: special considerations Technical assistance and resources Questions and answers

HSAG: Your Partner in Healthcare Quality HSAG is the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands. HSAG has been committed to improving healthcare quality for more than 35 years. QIN-QIOs in every state/territory are united in a network under the Centers for Medicare & Medicaid Services (CMS). The Medicare QIO Program is the largest federal program dedicated to improving healthcare quality at the community level.

HSAG’s QIN-QIO Territory Nearly 25 percent of the nation’s Medicare beneficiaries Drives quality by providing technical assistance, convening LANs, collecting and analyzing data for improvement Works on initiatives to improve patient safety, reduce harm, improve clinical care Engages healthcare providers, stakeholders, and beneficiaries to improve health quality, efficiency, and value. HSAG is the Medicare QIN-QIO for Florida, California, Ohio, Arizona, and the U.S. Virgin Islands.

Overview of MIPS Scoring

What Will Determine My MIPS Score?** The MIPS final score will factor in four weighted categories: MIPS Final Score Advancing Care Information Quality Cost Improvement Activities Many of you are probably wondering what will make up the MIPS final score. The score factors in performance in 4 weighted categories: quality, resource use, clinical practice improvement activities, and use of certified electronic health record (EHR) technology.   Most of these categories aren’t new to clinicians, who may have seen them before in programs such as PQRS. ** Beginning in 2018 Source: The Centers for Medicare & Medicaid Services

What Are the Performance Category Weights? Weights are assigned to each category based on a 1 to 100 point scale. 2017 Transition Year Performance Category Weights: Cost Improvement Activities Advancing Care Information Quality 60% 0% 15% 25% Source: The Centers for Medicare & Medicaid Services

How Much Can MIPS Adjust Payments? Based on a composite performance score, clinicians will receive +/- or neutral adjustments up to the percentages below. +7%+9% +4%+5% Adjusted Medicare Part B payment to clinician +/- Maximum Adjustments -4% -5% -7% So what does this payment adjustment look like? MIPS will adjust payments positively OR negatively based on a composite performance score for each clinician. The potential maximum adjustment percentage begins at +/- 4% in 2019 and will increase each year from 2019 to 2022. In 2022, the adjustment will be as high as +/- 9% [TRANSITION] -9% The potential maximum adjustment percent will increase each year from 2019 to 2022 2019 2020 2021 2022 onward MIPS Source: The Centers for Medicare & Medicaid Services

Connecting Final Score to Payment Adjustment 3+ points avoids the negative payment adjustment. 70+ points gains access to $500 million bonus pool for exceptional performers. Source: The Centers for Medicare & Medicaid Services

MIPS Reporting and Submission Methods What Do I Need to Know? 11

Individual vs. Group Reporting Options Individual Group 2. As a Group a) 2 or more clinicians (NPIs) who have reassigned their billing rights to a single TIN* b) As an Alternative Payment Model (APM) Entity 1. Individual—Under a National Provider Identifier (NPI) number and Tax Identifying Number (TIN) where they reassign benefits * If clinicians participate as a group, they are assessed as a group across all four MIPS performance categories. Source: The Centers for Medicare & Medicaid Services

Submission Methods Individual Group Quality Qualified Clinical Data Registry (QCDR) Qualified Registry EHR Claims QCDR Administrative Claims CMS Web Interface CAHPS for MIPS Survey Improvement Activities (IA) Attestation Advancing Care Information (ACI) CAHPS = Consumer Assessment of Healthcare Providers and Systems EHR = electronic health record Source: The Centers for Medicare & Medicaid Services 30

To Group or Not to Group Report as an individual Report with a group If you report as an individual, your payment adjustment will be based on your performance. Report with a group Each eligible clinician participating in MIPS via a group will receive a payment adjustment based on the group's performance. Source: The Centers for Medicare & Medicaid Services

MIPS Reporting and Participation Period What Do I Need to Know? 15

MIPS: Partial Participation for 2017 Submit 90 days of 2017 data to Medicare May earn a positive payment adjustment Submit a Partial Year “So what?”—If you are not ready on January 1, you can start anytime between January 1 and October 2. Need to send performance data by March 31, 2018 Source: The Centers for Medicare & Medicaid Services

MIPS: Full Participation for 2017 Submit a full year of 2017 data to Medicare May earn a positive payment adjustment Best way to earn largest payment adjustment is to submit data on all MIPS performance categories +% Key takeaway: Positive adjustments are based on the performance data on the performance information submitted, not the amount of information or length of time submitted. Submit a Full Year Source: The Centers for Medicare & Medicaid Services

Bonus Payments and Reporting Periods MIPS payment adjustment is based on data submitted. Clinicians should pick what's best for their practice. +% Submit a Full Year Submit a Partial Year Full year participation Is the best way to get the maximum adjustment Gives you the most measures to choose from Prepares you the most for the future of the program Partial participation (report for 90 days) You can still achieve the maximum adjustment Source: The Centers for Medicare & Medicaid Services

Performance Measure: Special Considerations

MIPS Scoring for Quality (60 Percent of Final Score in Transition Year) Select 6 of the approximately 300 available quality measures (minimum of 90 days) Or a specialty set Or CMS Web Interface measures Quick Tip: Easier for a clinician who participates longer to meet case volume criteria needed to receive more than 3 points. Bonus points are available 2 points for submitting an additional outcome measure 1 point for submitting an additional high-priority measure 1 point for using CEHRT to submit measures electronically end-to-end Clinicians receive 3 to 10 points on each quality measure based on performance against benchmarks. Failure to submit performance data for a measure = 0 points. Source: The Centers for Medicare & Medicaid Services

Use Benchmarks to Maximize Your Incentive Each measure is assessed against its benchmark. Benchmarks are specific to the type of submission mechanism: EHRs, QCDRs/registries, CAHPS, and claims. Benchmarks are based on actual performance data submitted to PQRS in 2015, except for CAHPS. Source: The Centers for Medicare & Medicaid Services

Choose Submission Methods Sample: Quality benchmarks for influenza Points depend on submission method. If 45 percent performance, note the difference:   Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10 Claims 22.64–31.75 31.76–43.13 43.14–54.68 54.69–66.38 66.39–77.47 77.48– 92.03 92.04–99.99 100 EHR 11.22–18.57 18.58–24.99 25.00–31.84 31.85–38.92 38.93–47.86 47.87–59.99 60.00–79.01 >= 79.02 Registry/ QCDR 11.57–21.39 21.40– 31.39 31.40–41.31 41.32–51.13 51.14–62.04 62.05–74.27 74.28–91.83 >= 91.84 If 45%, Claims falls into Decile 5 EHR falls into Decile 7 Registry/QCDR in Decile 6 Source: The Centers for Medicare & Medicaid Services

Number of Points Assigned for the 2017 MIPS Performance Period Table 1: Using Data in Benchmark to Estimate Points (For Non-Inverse Measures)* Decile Number of Points Assigned for the 2017 MIPS Performance Period Below Decile 3 3 points Decile 3 3–3.9 points Decile 4 4–4.9 points Decile 5 5–5.9 points Decile 6 6–6.9 points Decile 7 7–7.9 points Decile 8 8–8.9 points Decile 9 9–9.9 points Decile 10 10 points *For inverse measures, the order would be reversed. Where Decile 1 starts with the highest value and decile 10 has the lowest value. Source: The Centers for Medicare & Medicaid Services

Choose Your Measures Bang for buck: Measures that meet more than one MIPS performance category Example: Immunizations Quality: Measure ID #110 Influenza IA: Activity ID IA_CC_6 Participation in a QCDR Promote use of standard practices, tools and processes for quality improvement to document vaccinations ACI: Immunization Registry Reporting Active Engagement Performance score weight: 10 percent Source: The Centers for Medicare & Medicaid Services

Other Measures Documentation and Reconciliation of Medications Tobacco Use Screening and Cessation Opioid Management Closing the Referral Loop Source: The Centers for Medicare & Medicaid Services

MIPS Performance Category: Cost No reporting requirement; 0 percent of final score in 2017 Clinicians assessed on Medicare claims data CMS will still provide feedback on how you performed in this category in 2017, but it will not affect your 2019 payments. Keep in mind: Uses measures previously used in the Physician Value-Based Modifier program or reported in the Quality and Resource Use Report (QRUR) Only the scoring is different Source: The Centers for Medicare & Medicaid Services

MIPS Scoring for IA (15 Percent of Final Score in Transition Year) Total points = 40 Activity Weights Medium = 10 points High = 20 points Alternate Activity Weights* Medium = 20 points High = 40 points *For clinicians in small, rural, and underserved practices or with non-patient facing clinician groups Full credit for clinicians in a patient-centered medical home, Medical Home Model, or similar specialty practice Source: The Centers for Medicare & Medicaid Services

IA Tips 14 high-weighted activities 13 activities include QCDRs 1 needed for practice with 15 or fewer clinicians 2 needed for practice with 16 or more clinicians 13 activities include QCDRs For group reporting, only 1 MIPS-eligible clinician (EC) in a TIN must perform the Improvement Activity for the TIN to get credit. Source: The Centers for Medicare & Medicaid Services

IA Tips: Implement and Document Implement activities for at least 90 days Review activities in detail. Ask for team input. Discuss how to implement activities. Decide how to document activities, if audited. Document steps taken to implement IA Differs depending on Improvement Activities chosen Document Policy Agreement (TCPI, QIN-QIO) Keep for minimum of 6 years electronically and on paper. Receive 10 percent bonus points in ACI category by submitting using your certified EHR technology (CEHRT). TCPI = Transforming Clinical Practice Initiative Source: The Centers for Medicare & Medicaid Services

IA Tips: Access Provide patient access using CEHRT-patient portal ACI: Provide Patient Access Base score requirement Plus, Performance Score Weight Up to 20 percent IA: Activity ID IA_EPA_1—high weight Provide 24/7 access to ECs or groups who have real-time access to patient's medical record. Source: The Centers for Medicare & Medicaid Services

MIPS Performance Category: ACI (25 Percent of Final Score in Transition Year) Earn up to 155 percent maximum score, which will be capped at 100 percent. ACI category score includes: Required Base score (50%) Performance score (up to 90%) Bonus score (up to 15%) 50% 90% 15% Keep in mind: You need to fulfill the Base score or you will get a zero in the Advancing Care Information Performance Category. Source: The Centers for Medicare & Medicaid Services

MIPS Scoring for ACI (25 Percent of Final Score in Transition Year) Base score (worth 50 percent of ACI score) Clinicians must submit a numerator/denominator or Yes/No response for all required measures. Performance score (worth up to 90 percent of ACI score) Report up to 9 ACI Measures OR up to 7 2017 ACI Transition Measures Bonus score (worth up to 15 percent of ACI score) Receive 5 percent for reporting on Public Health and Clinical Data Registry Reporting measures Receive 10 percent for CEHRT to report certain IA ACI Performance Category Score = Base Score Performance Score Bonus Score Quick Tip: Maximum score cannot exceed 100% Source: The Centers for Medicare & Medicaid Services

Tips for ACI Success Schedule the 2015 EHR upgrade immediately. Understand the scoring methodology to maximize your score. Use high-functioning EHR for every possible process. Adopt patient-centric workflows. Emphasize preventive care. Perform daily team huddles. All clinicians and staff members should continue to suggest patient portals for every use to increase Patient Access to Information, HIE, Secure Messaging, and Patient Education. HIE = Health Information Exchange Source: The Centers for Medicare & Medicaid Services

Pursue Interfaces With EHR MIPS bonus points ACI—Immunization Registry 10 percent ACI—Specialized (Clinical Data) Registry 5 percent Quality - End-to-end electronic reporting 1 bonus point for each measure using CEHRT Up to 10 percent of the possible performance points in the Quality category 1 bonus point for each measure using CEHRT in end-to-end electronic reporting **For each measure totaling up to 10% of the possible performance points in the Quality category. Source: The Centers for Medicare & Medicaid Services

Maximize Electronic Exchange of Information Identify two or three trading partners of high referral or transfer of care volume. Apply effort to exchange in 2017 because MIPS 2018 will require more. 2015 CEHRT version has 2 requirements: Send Summary of Care Request/Accept Summary of Care 1. Send Summary of Care “For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider-(1) creates a summary of care record using certified EHR technology; and (2) electronically exchanges the summary of care record.” 2. Request/Accept Summary of Care “For at least one transition of care or referral received or patient encounter in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician receives or retrieves and incorporates into the patient's record an electronic summary of care document.” Source: The Centers for Medicare & Medicaid Services

Countdown to MIPS Data Submission https://goo.gl/jFiUgs

Technical Assistance and Resources

What Support Is Available to Clinicians? Full-service, expert help Quality Payment Program (QPP) Service Center QIN-QIOs QPP—Small, Underserved, and Rural Support (QPP-SURS) TCPI APM Learning Networks Self-service QPP Online Portal   In closing – HSAG is here to help with MIPS. [insert slide 17] CMS-awarded QPP Service Center for practices in Arizona. Source: The Centers for Medicare & Medicaid Services

Thank you! 40

CMS Disclaimer This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, with additional adapted material from Telligen, the QIN-QIO for Colorado, Iowa, and Illinois. The contents presented do not necessarily reflect CMS policy. Publication No. AZ-11SOW-D.1-09152017-01 41