Considerations for Choosing MIPS Quality Measures January 2018

RPA Guide to QPP Participation Overview of Contents First know yourself Finding measures Understanding scoring Special Considerations – about registries Special Considerations – ESRD patients Understanding the data that feeds measures – numerators, denominators, and excluders – OH MY! Data capture in the typical workflow Data quality and integrity Notes and considerations on reporting 2018 proposed CMS updates RPA Guide to QPP Participation

RPA Guide to QPP Participation First Know Yourself Quality measurement is dependent on making sure you are choosing measures that: Reflect the most typical care you or your practice provide Have reasonable distributions of performance (decile range benchmarks) so you can achieve high scores, even when you don’t have 100% performance Only use data that you have access to – data in separate fields that your electronic health record system can export for reports or use to calculate measure performance RPA Guide to QPP Participation

Identifying and Choosing Measures Library of Measures at qpp.cms.gov 271 measures currently approved Must know the requirements for complete data and choose the method of how you or your group want to submit data Important to remember that measures are benchmarked and earning a score is dependent on deciles of performance and the submission method. Decile of performance equals point score; e.g. 9th decile = 9 points Participant Submission Method Measure requirements Data Completeness Scoring Individual Part B Claims 6 measures or measure set 60% of Part B Patients for 12 months 1-10 points* Individual or Group QCDR, Qualified Registry, or EHR 60% of ALL patients who meet denominator inclusion criteria for 12 months *Small practices will still have 3 point floor Picture from http://healthcareblog.pyapc.com/2017/01/articles/pay-for-performance/optimizing-your-mips-score-quality-measure-benchmarks-and-reporting-mechanisms/ Keep 3-point floor for measures scored against a benchmark. Keep 3 points for measures that don’t have a benchmark or don’t meet case minimum requirement.  Measures that do not meet data completeness requirements will get 1 point instead of 3 points, except that small practices will continue to get 3 points. No change to bonuses.  Starting with the 2018 MIPS performance year, CMS proposes to use a cap of 7 points for a select set of 6 topped out measures: Topped out measures: For 2018, there are 6 topped out measures that be will scored with a maximum of 7-points instead of the standard 10-points: #21. Perioperative Care: Selection of Prophylactic Antibiotic-First or Second Generation Cephalosporin #23. Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) #52. Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy #224. Melanoma: Overutilization of Imaging Studies in Melanoma #262. Image Confirmation of Successful Excision of Image Localized Breast Lesion #359. Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT) Imaging Description All tables adapted from http://healthcareblog.pyapc.com/2017/01/articles/pay-for-performance/optimizing-your-mips-score-quality-measure-benchmarks-and-reporting-mechanisms/

Scores for MACRA/QPP – MIPS Quality Category Quality portion of MIPS composite score = 50 (out of 100) points for 2018 Your MIPS Quality score is based how well you perform on 6 chosen quality measures, where each measure is worth a maximum of 10 points. Groups of ≥16 clinicians will also be held accountable for a 7th measure – the AHRQ all cause hospital readmission measure. No reporting is required – data is aggregated and reported for you by CMS from claims data. There are bonus points achievable for choosing certain measures or using certified EHR technology (CEHRT). The 50 points of the MIPS composite score (MCS) is the % of points out of 60 (or 70 for groups >16) quality category points earned. RPA Guide to QPP Participation

MIPS – Quality Measure Score Card Example # of Cases Performance Points High Piriorty? Topped Out? CEHRT Use? Adjustment? Measure Score #1 20 4.1 N 1 5.1 #2 21 9.3 N/A Y -2.3 8 #3 22 10 11 #4 50 #5 43 8.5 9.5 #6 9.7 -6.7 3 All-Cause Readmission 205 5 Total Measure Score Points 51.6 Total Measure Score Points 51.6 Max Possible Quality Category Points 70 Quality Category Performance % 74% MIPS Composite Score - Quality Max 50 Points Earned Toward the Quality Category of MIPS Composite Score 37 Group ≥16 clinicians, therefore 70 maximum possible quality category points (All Cause Readmission measure calculated and applied by CMS) Used a CMS identified score-capped topped-out measure for #2, therefore 7 is maximal score(-2.3, but +1 bonus point for CEHRT use) Did not meet the minimum reported cases (20) for measure #6, there for score reduced to 3 (-6.7) Earned bonus points for reporting via CEHRT and choosing high priority measures (#1,2,3, and 5) Earned 69% of total possible quality points; 37/50 towards MCS score https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/QPP-Year-2-Final-Rule-NPC-Slides.pdf Example updated from MACRA final rule TABLE 19: Quality Performance Category Example with High Priority and CEHRT Bonus Points https://www.federalregister.gov/documents/2016/11/04/2016-25240/medicare-program-merit-based-incentive-payment-system-and-alternative-payment-model-incentive-under

Further Notes on Scoring of Measures Score is based on the performance decile achieved according to published, benchmarked distribution. CMS publishes benchmarks for all measures on QPP.CMS.GOV Many measures are topped-out, meaning there are very small performance differences separating the deciles. The same measure often has different benchmarks, depending on method of submission For 2017-2018 EHR submission has the lowest percentage of topped out measures Measures are scoring has become more complex in 2018 2018 Measure Scoring Adjustments of Note 3-point floor for measures scored against a benchmark (i.e. those CMS publishes) 3-point floor for measures that don’t have a benchmark (new QCDR custom measures) 3-point floor for measures that don’t meet case minimum requirement (<20 cases).  1-point floor for measures that do not meet data completeness requirements (60% of Part B patients who meet denominator - except that small practices will continue to get 3 points. 6-point ceiling for *some* topped out measures (list published by CMS) All tables adapted from http://healthcareblog.pyapc.com/2017/01/articles/pay-for-performance/optimizing-your-mips-score-quality-measure-benchmarks-and-reporting-mechanisms/

RPA Guide to QPP Participation Notes on Registries Qualified Registries (QRs) are approved vendors that aggregate and report quality data on behalf of subscribing clinicians and practices. MIPS wizard is an example. QCDRs (Qualified Clinical Data Registry) are databases that allow the collection and submission of the data needed to report on quality measures. QCDRs differ from Qualified Registries (QRs) in that QCDRs will offer both standard quality measures as well as custom, CMS-approved quality measures that are not available in standard MIPS library of measures published by CMS. These custom measures may be specific to a disease or specialty of medicine. RPA’s Kidney Quality Improvement Registry (a QCDR) is an example. Both QRs and QCDRs typically charge subscription fees and may offer various visualization and other tools, beyond simple data aggregation and reporting RPA Guide to QPP Participation

Notes about ESRD patients There is a lot of confusion about the ”requirements” for reporting across MIPS categories on ESRD patients. At a minimum (and depending on how a clinician or group reports data), CMS requires reporting on 60% of Part B patients who fall in the denominator of a chosen measure. When choosing measures, the types of encounters (based on CPT code) and/or disease state based on (ICD-10) will determine which patients count in the denominator. There are very few measures that include the dialysis CPT codes (909XX) or N18.6 in the denominator. However, if a chosen measure does include ESRD services or patients, how to capture other needed data for the measure on enough patients will have to be considered, given that EHR system use and robust data capture are not as easy in the dialysis setting. RPA Guide to QPP Participation

RPA Guide to QPP Participation Understanding the data that feeds measures – numerators, denominators, excluders, OH MY! For each chosen measure, it is important to ensure that for each data element required the following is known: Where it is captured in the practice workflow? Who is responsible for capturing it? Which field-specific data must be entered in the EHR? What the acceptable range of responses are for each specific data element needed? RPA Guide to QPP Participation

Denominator Inclusion Example – Smoking Cessation – CMS #226 Preventative Care and Screening: Tobacco Use Measure: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user Denominator Inclusion Numerator Inclusion Numerator Exclusion Age > 18 on or after time of visit • reports no tobacco use • NOT Screened for tobacco use and • circumstances document (terminal illness, etc.) or A patient encounter resulting in a CPT list defined by CMS* *90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 97003, 97004, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99406, 99407, G0438, G0439 • Reports current tobacco use No Screening and/or no intervention for other documented reason • received counseling (3 min or less), pharmacotherapy, or both No Screening and/or no intervention without documentation(measure not met) RPA Guide to QPP Participation

Measure #226 Data Workflow and CPTs to be reported These are CPT II codes For reporting quality measures Measure #226 Data Workflow and CPTs to be reported Report CPT 4004F Report CPT 1036F Report CPT 4004F-1P From https://pqrs.cms.gov/dataset/2016-PQRS-Measure-226-11-17-2015/s8gr-6b6i/data Report CPT 4004F-8P From https://pqrs.cms.gov/dataset/2016-PQRS-Measure-226-11-17-2015/s8gr-6b6i/data

Matching Data Requirements to Workflow: Measure #226 Example Required Data How and Where is this data typically captured? Who Captures the data? Age≥ 18 @ time of visit Typically calculated from DOB in EHR Front office staff Visit CPT code Chosen by provider @ time of encounter completion/bill generation Provider (possibly coder) Date of visit Automatically calculated based on date of service Auto generated Reports current tobacco use? Typically a checkbox or part of social history – varies on EHR Provider/Medical Assistant/Nurse If tobacco user, was counseling provided? May be a CPT code, may be a separate checkbox – varies by EHR Provider If tobacco user, was pharmacotherapy prescribed? May be a checkbox, may be based on specific Rx given during or after the visit completion – varies by EHR

Considerations on Data Capture What practice-level incentives are in place to ensure staff and clinicians are capturing the right data, in the right place, and at the right time? What and how often are reports reviewing the quality and completeness of the data captured being run? Who reviews these reports? How is feedback offered to correct or acknowledge data capture behavior? What mechanisms, policies, and/or procedures are in place to amend the medical record if problems of missing or inaccurate data are discovered? For your EHR and other data tools, what is the time lag between when data is recorded/entered in the EHR to when scorecards or quality measure reports are updated for review? RPA Guide to QPP Participation

Considerations on Reporting Data to CMS… Before allowing your registry vendor (QR, QCDR, or your EHR acting in the role of QR) to submit data, consider the following: Have you confirmed what measures will be reported to CMS? Have you reviewed the data to be submitted for each clinician and checked it against internal reports? Will you have confirmation of transmission to CMS AND a copy of the exact data file(s) sent? Are you aware of when and how CMS will report their calculated MIPS score for your practice and/or clinicians? Are you aware of the deadlines and steps CMS offers to appeal/amend scoring on submitted quality (and other) data? RPA Guide to QPP Participation

RPA Guide to QPP Participation Updates for 2018: (see https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/QPP-Year-2-Final-Rule-NPC-Slides.pdf) CMS now has a nephrology-specific quality measure bundle (See appendix table B.21 in the proposed rule and the next slide) CMS now offers a bonus of up to 10 % in the quality category (5 MCS points) for clinicians or groups that show significant year to year improvement between 2017 and 2018 performance. CMS may accept data from more than one submission method for a single category beginning in 2019. This may ease some burden of reporting quality on ESRD patients when data is gathered in multiple EHRs (office and dialysis unit-based). Please see CMS website for more information RPA Guide to QPP Participation

RPA Guide to QPP Participation 2018 Nephrology-Specific Quality Measure Bundle Table B.21 in the proposed rule RPA Guide to QPP Participation

RPA Guide to QPP Participation For additional resources, including a list of MIPS measures relevant to nephrology, visit www.renalmd.org/physiciandevelopment RPA Guide to QPP Participation