1. MIPS Quality Component
MACRA
Quality Payment Program
MIPS Quality Component
Jill Sage | Quality Affairs Manager
Division of Advocacy and Health Policy

2. MIPS Quality Component
Overview of the quality data submission requirement
Reporting options and quality measures
Scoring the quality component
Tips on how to be successful
High priority is defined as outcome measure, appropriate use measure, patient experience, patient safety, efficiency measures, or care coordination
Quality Payment Program
MIPS Quality Component

3. MIPS: 2019 Payment Adjustment*
*CY 2019 payment adjustments based on CY 2017 performance
Quality
(60%)
ACI
(25%) IA
(15%)
Final
Score
Cost
(0%)
Quality Payment Program
MIPS Quality Component

4. MIPS: Quality Data Submission Criteria
MIPS submission mechanisms:
Qualified Clinical Data Registry (QCDR), Qualified Registry, EHR, Claims
Report a minimum of six measures, including:
One outcome measure OR
One high-priority measure if an outcome measure is not available
Report on 50 percent of all-payer patients (50 percent of Medicare patients for claims reporting)
Composite Performance Score (CPS)
High priority is defined as outcome measure, appropriate use measure, patient experience, patient safety, efficiency measures, or care coordination
Quality Payment Program
MIPS Quality Component

5. Pick Your Pace in MIPS: Quality Performance Category
Do Nothing
Test Pace
Partial Participation
Full Participation
Do nothing
Get a 4 percent penalty
Report one quality measure for at least one patient
Avoid 4 percent penalty
Report six quality measures for a minimum of 90 days, including one outcome or one high-priority measure
May earn a positive adjustment
Report six quality measures for a full year, including one outcome or one high-priority measure
May earn a positive adjustment
Quality Payment Program
MIPS Quality Component

6. Important to Note
Positive adjustments are based on performance, not the amount of information or length of time providers reported
Quality Payment Program
MIPS Quality Component

7. MIPS: Quality Measures
Surgeons can select six measures from:
List of approximately 300 MIPS quality measures
Specialty-specific set of measures
Qualified Clinical Data Registry (non-MIPS measures)
Groups can continue to report via the Centers for Medicaid & Medicare Services (CMS) Web interface or Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS
Composite Performance Score (CPS)
High priority is defined as outcome measure, appropriate use measure, patient experience, patient safety, efficiency measures, or care coordination
Quality Payment Program
MIPS Quality Component

8. Specialty-Specific Measure Set Example
General Surgery
Perioperative Care: Selection of Prophylactic Antibiotic—First OR Second Generation Cephalasporin
Anastomotic Leak Intervention
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
Unplanned Reoperation within the 30-Day Postoperative Period
Care Plan
Unplanned Hospital Readmission within 30 Days of Principal Procedure
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Surgical Site Infection (SSI)
Documentation of Current Medications in the Medical Record
Patient-Centered Surgical Risk Assessment and Communication
Preventive Care and Screening: Tobacco Use—Screening and Cessation Intervention
Closing the Referral Loop: Receipt of Specialist Report
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Tobacco Use and Help with Quitting among Adolescents
Composite Performance Score (CPS)
Report at least 6 measures, or if less than 6 are applicable report on each measure that is applicable:
Quality Payment Program
MIPS Quality Component

9. MIPS: ACS Registries for 2017 MIPS Reporting
The ACS has two registries that can be used for reporting MIPS for 2017: The Surgeon Specific Registry (SSR) and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)
Composite Performance Score (CPS)
Offers two submission mechanisms:
QCDR (non-MIPS measures)
Traditional registry (MIPS measures)
Offers the QCDR (non-MIPS measures) submission mechanism
Allows flexibility for more meaningful specialty-specific measures
Quality Payment Program
MIPS Quality Component

10. MIPS: Scoring for Quality
Three to 10 points on each quality measure based on performance against benchmarks
Bonus points available:
Two bonus points for each additional outcome or patient experience measure; one bonus point for each additional high- priority measure
One point for end-to-end electronic reporting
Failure to submit data will result in a score of zero
Composite Performance Score (CPS)
Capped at 10% of the denominator
Quality Payment Program
MIPS Quality Component

11. MIPS: Tips for Success in Quality
Report on at least six measures, with as many outcome and high- priority measures as you can
Report for a time period that will allow you to have reliable data or at least meet the minimum case volume
Review your PQRS Feedback Reports
Utilize ACS resources, including ACS registries available for reporting MIPS
Quality Payment Program
MIPS Quality Component