A Physician’s Perspective: Strategies for Achieving the Best Score in MIPS Performance July 14, 2017 Deborah Tracy MD, MBA

Disclaimer HSAG remains a neutral vendor and today’s speaker is one of many experts on subjects of topical interest.

Deborah Tracy, MD, MBA - Board Certified Anesthesiologist - Subspecialty Certified Pain Management, ABA - Fellow of the Interventional Pain Practice, WIP - Board Certified Pain Management, ABIPP

Objectives Identify strategies to maximize scoring potential in the Merit-based Incentive Payment System. Recognize how to calculate your MIPS composite score Discuss how to access your QRUR report to monitor the Cost MIPS performance category

Most Clinicians Subject to MIPS

Percentage of MIPS Categories

Who Is Excluded from MIPS? Eligible: Greater than $30,000 AND Greater than 100 Medicare Part B Fee-for-Service patients

Reporting as Individual or Group

Group Reporting Example

Pick Your Pace *** ***No downside to report ONE measure or IA

MIPS Adjustment Based on a MIPS Composite Performance Score, clinicians will receive +/- or neutral adjustment up to the percentages below.

MIPS Incentive Payment Formula > 70 points Note that between the ‘haves’ and the ‘have nots’ the maximum bonus: 2019 high as 22% 2020 bonus could be 37%.

Scores and Publication Publication - Each clinician’s annual final score is released to the public by CMS on Physician Compare Reputational Impact - Score follows clinician for 2 years 62% of patients use internet ratings Scores - CMS sets a performance threshold (PT) For 2017: Performance threshold as 3 points minimum per measure Exceptional performance threshold to 70 points

Percentage of MIPS Categories (cont.)

QUALITY

Quality, 60% of Score = 60 points Each measure can max at 10 points: Total = 60 quality points + 6 bonus points Each measure earns up to 10 points based upon the percentile-basis performance of that measure relative to national peer benchmarks One must be an outcome measure or a high priority measure Example: 62% measure 60% of peers reflected in the benchmark for the measure

Example of Using Benchmarks for a Single Measure to Assign Points Decile Sample Quality Measure Benchmarks Possible Points Decile 1 0 - 6.9% 1.0 - 1.9 Decile 2 7.0 - 15.9% 2.0 - 2.9 Decile 3 16.0 - 22.9% 3.0 - 3.9 Decile 4 23.0 - 35.9% 4.0 - 4.9 Decile 5 36.0 - 40.9% 5.0 - 5.9 Decile 6 41.0 - 61.9% 6.0 - 6.9 Decile 7 62.0 - 68.9% 7.0 - 7.9 Decile 8 69.0 - 78.9% 8.0 - 8.9 Decile 9 79.0 - 84.9% 9.0 - 9.9 Decile 10 85.0 - 100% 10

QUALITY (cont.)

BENCHMARKS BIG CHANGE!

2017 Benchmarks qpp.cms.gov Education & Tools – Scroll Down Last Column = Topped Out

2017 Benchmarks Table 2: MIPS Benchmark Results Measure_Name Measure_ID Submission_Method Measure_Type Benchmark Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10 Topped Out Diabetes: Hemoglobin A1c Poor Control 1 Claims Outcome Y 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 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 Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade 100 Process -- Yes 83.96 - 96.96 96.97 - 99.99 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients 102 42.12 - 54.99 55.00 - 71.72 71.73 - 82.13 82.14 - 99.46 99.47 - 99.99 Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients 104 77.31 - 80.64 80.65 - 91.19 91.20 - 96.66 96.67 - 98.82 98.83 - 99.99 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment 107 53.85 - 64.74 64.75 - 70.90 70.91 - 86.68 86.69 - 89.31 89.32 - 92.90 92.91 - 96.54 96.55 - 98.67 >= 98.68 Osteoarthritis (OA): Function and Pain Assessment 109 80.92 - 94.14 94.15 - 98.67 98.68 - 99.99 5.16 - 14.84 14.85 - 37.78 37.79 - 65.33 65.34 - 88.04 88.05 - 97.81 97.82 - 99.99 Preventive Care and Screening: Influenza Immunization 110 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 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 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 Pneumonia Vaccination Status for Older Adults 111 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 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 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 Breast Cancer Screening 112 38.46 - 48.01 48.02 - 55.67 55.68 - 62.78 62.79 - 69.41 69.42 - 77.18 77.19 - 87.87 87.88 - 98.52 >= 98.53 12.41 - 22.21 22.22 - 32.30 32.31 - 40.86 40.87 - 47.91 47.92 - 55.25 55.26 - 63.06 63.07 - 73.22 >= 73.23 14.49 - 24.52 24.53 - 35.70 35.71 - 46.01 46.02 - 55.06 55.07 - 63.67 63.68 - 74.06 74.07 - 87.92 >= 87.93 Colorectal Cancer Screening 113 29.50 - 42.36 42.37 - 53.84 53.85 - 64.40 64.41 - 75.40 75.41 - 84.67 84.68 - 93.13 93.14 - 99.99

Assessment in Benchmark Table, 2017 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 128 Claims Process Y 41.33 - 45.76 45.77 - 51.46 51.47 - 66.43 66.44 - 90.09 90.10 - 98.60 98.61 - 99.99 -- 100 No EHR 28.73 - 31.80 31.81 - 34.45 34.46 - 37.23 37.24 - 40.19 40.20 - 43.64 43.65 - 48.75 48.76 - 68.18 >= 68.19 Registry/QCDR 39.80 - 45.63 45.64 - 50.91 50.92 - 56.68 56.69 - 64.88 64.89 - 75.81 75.82 - 87.12 87.13 - 97.33 >= 97.34 Documentation of Current Medications in the Medical Record 130 Claims Process Y 96.11 - 98.73 98.74 - 99.64 99.65 - 99.99 -- 100 Yes EHR 76.5 - 87.88 87.89 - 92.73 92.74 - 95.35 95.36 - 97.08 97.09 - 98.27 98.28 - 99.12 99.13 - 99.75 >= 99.76 Registry/QCDR 61.27 - 82.11 82.12 - 91.71 91.72 - 96.86 96.87 - 99.30 99.31 - 99.99 Diabetes: Foot Exam 163 Claims Process Y 37.84 - 54.28 54.29 - 71.87 71.88 - 86.51 86.52 - 96.66 96.67 - 99.99 -- 100 No EHR 5.31 - 10.90 10.91 - 19.99 20.00 - 29.26 29.27 - 38.77 38.78 - 50.09 50.10 - 62.60 62.61 - 76.16 >= 76.17 Registry/QCDR 6.14 - 14.70 14.71 - 25.57 25.58 - 39.80 39.81 - 55.87 55.88 - 72.21 72.22 - 86.43 86.44 - 98.03 >= 98.04 Falls: Screening for Future Fall Risk 318 EHR Process Y 6.33 - 17.92 17.93 - 31.98 31.99 - 47.86 47.87 - 63.81 63.82 - 81.04 81.05 - 90.20 90.21 - 98.49 >= 98.50 No Registry/QCDR 0.11 - 0.11 0.12 - 0.14 0.15 - 0.20 0.21 - 0.28 0.29 - 0.50 0.51 - 55.23 55.24 - 92.20 >= 92.21

How many measures should be reported? Report 6 measures with the best performance.  Review in 2017 Quality Benchmarks document what score is needed to score 10 points for each measure Report more than 6 measures only if they have high performance            Do not report ‘everything but the kitchen sink’ because the poor quality measures will be published

Calculation of Quality Points Example: 6 measures = 7 points each Total points 6 x 7 = 42 out of 60 points 42/60 =70% of the 100% (60 points) for Quality CY2017 performance year Quality has a weight of 60% Quality score of 70% Quality category contributing 70% x 60% x 100 = 42 MIPS points to the clinician’s overall MIPS final score

QUALITY: MIPS If bonus points are available a score of > 100% is truncated back to 100%

Quality, Bonus Points 6 POINTS MAXIMUM The maximum number of bonus points for high priority measures for the Quality Performance Category score is 10% of the possible points; however, the bonus can be lower than that maximum. As an example, for an individual reporter that can report at least 6 measures, the maximum number of bonus points is 6 points for the entire category because the possible points is 60 (6 measures x 10 points per measure). If the clinician only submits one additional outcome measure, then the total bonus points would be 2; in no case would the number of bonus points be greater than 6. CMS Query

Reporting Tips Don’t report everything but the kitchen sink Each measure will be available publically Physician Compare, Yelp, Consumer Reports They will choose the top six, but may not choose the ones you think are best Only report high scoring measures Score will follow clinician, even if he/she changes TINs Measure Groups are gone If an individual clinician has a low threshold - think about reporting as a group

QUALITY (60%) QUALITY REPORTING Individuals report through: Claims (NQFs) Qualified Registry (NQFs) Specialty Registry – QCDR, Qualified Clinical Data Registry EHR – eCQMs Data Submission Vendor, DSV

CMS eCQMs Library

EC CLINICAL QUALITY MEASURES FOR EHR INCENTIVE PROGRAMS Website for EHR eCQMs https://ecqi.healthit.gov/eligible-professional-eligible-clinician-ecqms

Percentage of MIPS Categories

Advanced Care Information (ACI) (25%) Fulfill the required measures for a minimum of 90 days Base Points = 50 Points Security risk analysis – Conduct or review a security risk analysis that addresses security of electronic patient health information (PHI) and implements security updates to identify risks; Security Risk Analysis https://www.healthit.gov/providers-professionals/security-risk-assessment-tool E-prescribing – Electronically query for and transmit at least at least one prescription; Provide patient access – Provide patients with timely access to electronically view, download and transmit health information, or offer access in an application of their choice Send summary of care – Electronically create a summary of care and exchange summary of care to another provider when patients transition to another care setting; and Receive summary of care – Electronically receive summary care record when patient is transitioning from another care setting and incorporate into EHR. Performance Score = 90 Points Public Health Registry Bonus = 1 - 15 Points TOTAL = 155 POINTS

ACI Base Score Requirements To satisfy base score requirements eligible clinician only need one (1) patient in the numerator of the base measures 2 measures overlap and achieving a high numerator gets extra bonus points

ACI Base Score Example Scoring Example: Base Score (12.5 points) Measure Result Security Risk Analysis Yes E-Prescribing 1/500 Provide Patient Access 1/500 Send Summary of Care 1/500 Accept Summary of Care 1/500

Advancing Care Information

ACI

ACI (cont.)

ACI: Flexibility

ACI Scoring for Hospital Based

Scoring Performance Category Security risk E-prescribing Provide patient access Send summary of care Receive summary care Scoring Performance Category

ACI Scoring Performance Measures

ACI Performance Scoring

ACI: Performance Score EXAMPLE: OBJECTIVES AND MEASURES PERFORMANCE SCORE (90%) Measure Num/Denominator Performance Rate Percentage Score Provide patient access 250/500* 50% 5% Patient specific education 15/500 3% 1% View, download transmit 300/500 60% 6% Send a summary of care 450/500* 90% 9% Accept a summary of care 277/500* 55% Registry reporting yes Total Performance 32%

Bonus Points

ACI Scoring

ACI Example Bonus Point Scoring ACI: OBJECTIVES AND MEASURES BONUS POINTS MEASURE RESULT SCORE Specialized registry reporting YES 5% Reporting IA improvements thru CEHRT 10% BONUS POINTS 15%

Advancing Care Information Attestation Public Health Registry Bonus Point: Immunization registry reporting is required. In addition, clinicians may choose to report on more than one public health registry, and will receive one additional point for reporting beyond the immunization category State Prescription Drug Monitoring Program (PDMP) for pain physician will count Section 10 Attestation - Public Health - Specialized Registry Reporting MU 2016 Objective 10 Measure #3

Credit for Specialized Registry, #3 State PDMP FLORIDA E-FORCSE MEANINGFUL USE ATTESTATION— Retrieval of Patient Information Florida’s Prescription Drug Monitoring Program, E-FORCSE, maintained by the Florida Department of Health (FDOH) meets the definition of a specialized registry. Below is an explanation designed to help Eligible professionals (EPs) get started and prepared for Meaningful Use (MU) Stage 2 Specialized Registry attestation regarding retrieval of patient specific controlled substance dispensing information. On January 1, 2016, Florida’s Prescription Drug Monitoring Program, E-FORCSE, maintained by the Florida Department of Health (FDOH) identified itself as a specialized registry.  EPs can meet the MU Stage 2 Specialized Registry objective by complying with one of the following: EPs may submit patient specific controlled substance dispensing information electronically to E-FORCSE; or EPs may electronically retrieve patient specific controlled substance dispensing information from E-FORCSE. Open an Internet browser window and type the following URL in the address bar: www.hidesigns.com/flpdmp

Total ACI Score In ACOs the ACI category is reported for each TIN One additional public health reporting = 5 points Cross-category bonus by reporting IA thru CEHRT = 10 points All numerators greater than zero Each Scored on Decile System

ACI: Example Total Score BASE SCORE 50% PERFORMANCE MEASURE SCORE 32% BONUS SCORE 15% TOTAL SCORE 97% FINAL SCORE X 0.97 = 24.25 POINTS

ACI: Transition Year

ACI Bonus Points for Reporting IA

Percentage of MIPS Categories IA

MIPS, Improvement Activities (15%) Report 40 points in Improvement Activities to earn 100% in this category Small practices (15 or less clinicians); practices located in rural areas or geographic HPSAs, or non-patient facing 20 points weight for medium activities and 40 points weight for high activities All other MIPS-eligible clinicians 10 points weight for medium activities and 20 points weight for high activities Bonus Point for using activities that employ EHR Report any combination of medium-weight and/or high-weight activities Activities such as expanded practice access; population management; care coordination; beneficiary engagement; patient safety and practice assessment; and participation in an APM. Clinicians would select from a list of available activities. https://qpp.cms.gov/measures/ia Nine categories, 90+ choices Expanded patient access Safety Same day appointments Patient engagement Population management Patient and practice assessment Emergency preparedness and response Care Coordination Regular, formal staff meetings Participating in an PCMH Integrated behavioral and mental health MOC

Improvement Activities

MIPS Scoring for Advancing Care Information (20 for < 15 ECs)

MIPS 2017, COST (0%) COST (0%), 2017 Does not require reporting Replaces VBM, CMS will calculate these scores based on Medicare claims Does not require reporting Based on the TIN that provided more Primary Care services to the beneficiary (as measured by Medicare-allowed charges) Standardized algorithms Risk Adjust, Hierarchical Condition Categories (HCC) Ordinary least squares regressions Truncated expected values Winsorize observed episode costs Standardized spending levels Calculate predicted episode costs Standard Deviations Actuarial Adjustments

Percentage of MIPS Categories Cost

COST

Example 1: Calculating a Final Score Assuming that the numerical examples used for the four categories as described above all apply to the same clinician, we can calculate a total Final Score from the components: Quality = (42 of 60 points) x 60% weight x 100 = 42 points ACI = (50 of 100 points) x 25% weight x 100 = 12.5 points IA = (30 of 40 points) x 15% weight x 100 = 11.3 points (rounded up from 11.25) COST = 0% weight x 100 = 0 Final Score Total Final Score = 42 + 12.5 + 11.3 + 0 = 65.8

Example 2: Calculating a Final Score Assuming that the numerical examples used for the four categories as described above all apply to the same clinician, we can calculate a total Final Score from the components: Quality = (60 points) x 60% weight x 100 = 60 points ACI = (97 of 100 points) x 25% weight x 100 = 24.5 points IA = (40 points) x 15% weight x 100 = 15 points COST = 0% weight x 100 = 0 Final Score Total Final Score = 60 + 24.5 + 15 + 0 = 99.5 YOU ARE AN EXCEPTIONAL PERFORMER!

Transition Year 2017

Reporting Your Data to CMS

When Does MIPS Begin?

QRUR Quality Resource Use Report COST $$$

What Information Is Contained in the 2015 Annual QRUR?

QRUR, Pain, 2015 x

THE END! Thank you for participating. That concludes the presentation part of the session today and we thank you for joining us.

Questions?

QPP Technical Assistance Resource Guide Below is a link to the QPP TA Resource guide for small and large practices. To locate a Small Underserved Rural Support QPP contractor, click on the link and a resource will appear directing you the state point of contact in your area. https://qpp.cms.gov/docs/QPP_Technical_Assistance_Resource_Guide.pdf Source: The Centers for Medicare & Medicaid Services

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