1. Quality Reporting in a MACRA World
College of Imaging Administrators Spring Assembly
Susan Hollabaugh March 2017

2. Medicare Access and CHIP Reauthorization Act
Repealed the Sustainable Growth Rate Formula
Established the Quality Payment Program (QPP)
There are two tracks under the QPP
Advanced Alternative Payment Models (APMs)
Merit-based Incentive Payment System (MIPS).
Quality Reporting in a MACRA World
May 2017

3. Does the Quality Payment Program Apply to My Practice?
Eligible Clinicians: Physician, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist
Bill Medicare more than $30,000 in Part B allowable charges a year AND provide care for more than 100 Medicare patients a year.
If this is your first year participating in Medicare then you are not part of QPP
Medicare has begun mailing out MIPS Participation Status Letters
Providers reporting under multiple TINs (tax id) will need to report for each TIN+NPI combination
Quality Reporting in a MACRA World
May 2017

4. Other Definitions to Know
Non-Patient Facing Clinicians- Bills 100 or fewer patient- facing encounters during the determination period.
Non-Patient Facing Group- Greater than 75% of NPIs in the group are non-patient facing.
Hospital-based provider – 75% or more of covered Medicare professional services are billed with POS codes 21, 22, or 23.
Non-patient facing and Hospital-based providers are not required to submit Advancing Care Information (ACI) measures, however if submitted, ACI will be included in the MIPS score.
Quality Reporting in a MACRA World
May 2017

5. What is an Advanced APM?
In 2017, the following models are Advanced APMs:
Comprehensive ESRD Care (CEC) - Two-Sided Risk
Comprehensive Primary Care Plus (CPC+)
Next Generation ACO Model
Shared Savings Program - Track 2
Shared Savings Program - Track 3
Oncology Care Model (OCM) - Two-Sided Risk
Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1- CEHRT)
25% of Medicare payment must come through the Advanced APM
–OR—
20% of your Medicare patients are seen through an Advanced APM
Quality Reporting in a MACRA World
May 2017

6. What is MIPS?
Federal initiative that links fee-for-service (FFS) payment to value and quality.
Purpose is to simplify multiple existing programs and emphasize value over volume.
Eligible providers can submit performance measures to qualify in 2017.
CMS scores performance on four categories, for a total score between
That score determines payment adjustments.
Can participate in MIPS as a Group or Individual.
Quality Reporting in a MACRA World
May 2017

7. IMPROVEMENT ACTIVITIES (IA) ADVANCING CARE INFORMATION (ACI)
MIPS Categories
QUALITY
The majority of your score, six measures required
IMPROVEMENT ACTIVITIES (IA)
Focus on improved outcomes, scoring scaled to difficulty across 92 activities
ADVANCING CARE INFORMATION (ACI)
Focus on certified technology and interoperability, replaces MU
COST
Comparison among similar providers, weighted heavily in 2018 and beyond
Quality Reporting in a MACRA World
May 2017

8. IMPROVEMENT ACTIVITIES (IA) ADVANCING CARE INFORMATION (ACI)
MIPS Categories
Majority of your score, as much as 85%.
Reporting on six measures required, minimum of 20 cases required.
At least one measure is an outcome measure, or high priority measure.
Groups of over 16 Eligible Clinicians will have a seventh measure- Measure 458 automatically calculated. (All Cause Readmission Measure)
QUALITY
The majority of your score
IMPROVEMENT ACTIVITIES (IA)
Focus on improved outcomes, scoring scaled to difficulty across 92 activities
ADVANCING CARE INFORMATION (ACI)
Focus on certified technology and interoperability, replaces MU
COST
Comparison among similar providers, weighted heavily in 2018 and beyond
Quality Reporting in a MACRA World
May 2017

9. IMPROVEMENT ACTIVITIES (IA) ADVANCING CARE INFORMATION (ACI)
MIPS Categories
As much as 15% of your score.
Use of patient surveys, registry reporting, patient engagement and use of Clinical Decision Support included.
QUALITY
The majority of your score
IMPROVEMENT ACTIVITIES (IA)
Focus on improved outcomes, scoring scaled to difficulty across 92 activities
ADVANCING CARE INFORMATION (ACI)
Focus on certified technology and interoperability, replaces MU
COST
Comparison among similar providers, weighted heavily in 2018 and beyond
Quality Reporting in a MACRA World
May 2017

10. IMPROVEMENT ACTIVITIES (IA) ADVANCING CARE INFORMATION (ACI)
MIPS Categories
ACI replaces Meaningful Use.
Consider reporting if it’s found to boost the overall score of a Practice.
In that case, ACI would represent 25% of total score, and Quality 60%.
QUALITY
The majority of your score
IMPROVEMENT ACTIVITIES (IA)
Focus on improved outcomes, scoring scaled to difficulty across 92 activities
ADVANCING CARE INFORMATION (ACI)
Focus on certified technology and interoperability, replaces MU
COST
Comparison among similar providers, weighted heavily in 2018 and beyond
Quality Reporting in a MACRA World
May 2017

11. IMPROVEMENT ACTIVITIES (IA) ADVANCING CARE INFORMATION (ACI)
MIPS Categories
Cost will be scored.
Score will not be weighted toward the final grade this year.
QUALITY
The majority of your score
IMPROVEMENT ACTIVITIES (IA)
Focus on improved outcomes, scoring scaled to difficulty across 92 activities
ADVANCING CARE INFORMATION (ACI)
Focus on certified technology and interoperability, replaces MU
COST
Comparison among similar providers, weighted heavily in 2018 and beyond
Quality Reporting in a MACRA World
May 2017

12. Pick Your Pace NOT PARTICIPATING in the Quality Payment Program:
If you don’t send in any 2017 data, then you receive a negative 4% payment adjustment.
TEST:
If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity for any point in 2017), you can avoid a downward payment adjustment.
PARTIAL:
If you submit 90 days of 2017 data to Medicare, you may earn a neutral or positive payment adjustment and may even earn the max adjustment.
FULL:
If you submit a full year of 2017 data to Medicare, you may earn a positive payment adjustment.
Quality Reporting in a MACRA World
May 2017

13. Quality Submission Method – A Key Decision
Web Interface – must register, will report for the whole year on 15 measures
Electronic Health Record (EHR) – bonus points for end to end reporting
Claims (just Medicare patients)
Registry (all patients not just Medicare)
Qualified Registry
Qualified Clinical Data Registry (QCDR) – bonus points, additional measures
Quality Reporting in a MACRA World
May 2017

14. Quality Submission Method – A Key Decision
Of the 14 Diagnostic Radiology measures:
0 are available through the Web Interface
0 are available through EHR submission
8 are available through Claims submission
14 are available through Registry submission*
*If you submit through a QCDR additional measures are available
Measure Set submission is no longer available, providers should pick measures in their ‘Specialty Set’ or measures that apply to their scope of practice
If you are a participant in an ACO, measures will be reported for you by the ACO. You do not need to do anything to report measures for MIPS. Your MIPS score will be the same as the score received by the ACO.
Quality Reporting in a MACRA World
May 2017

15. Quality Measures - Key Points
Some measures have bonus points
Outcome (listed in 2017 Benchmark Report)
High Priority (listed in 2017 Benchmark Report)
Registry and claims measure specifications are not the same
Denominators (what exams are in the population being measured)
Numerators (did the exam meet the measure or not)
Exclusions (some measures exclude certain exams)
Some measures are inverse - the lower the performance rate the better.
Radiology measures are Quality coded based on what is in the radiologist report
Monitor how the radiologists are doing with quality reporting as real time as possible.
Strong performance rates require communication between those that monitor quality measures and the radiologists.
Work with the radiologists to come up with standard templates that meet the mark.
Make sure to work with anyone that is producing final radiology reports, including tele-radiologists.
Quality Reporting in a MACRA World
May 2017

16. Measure 145: Exposure Dose or Time Reported for Procedures Using Fluoro
Denominator- long list of CPT codes using Fluoro
Numerator – Final fluoro reports including radiation exposure indices, or exposure time and number of images (if indices are not available.)
G9500 – performance met
G9501 – performance not met
The scoring system under MIPS is different then PQRS.
Numerator (measure met) divided by Denominator gives us the Performance Rate, compare this to the 2017 Benchmark Report to find your ‘decile’ score. Deciles are then translated into points.
Quality Reporting in a MACRA World
May 2017

17. Submission method impacts points
Measure ID
Submission Method
Decile 3 4 5 6 7 8 9 10
145
Claims
100
Registry/CDR
If my performance rate is 90% and submitted via claims my Decile is 5.
My score via registry with the same performance rate would be Decile 6.
In this example, there is over a 5% percentage point difference between claims and registry reporting.
Decile 5
84.62-
89.77
Quality Reporting in a MACRA World
May 2017

18. Measure Scoring- Benchmarks in ‘Deciles’
Number of Points Assigned for the 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.
Quality Reporting in a MACRA World
May 2017

19. Quality Scoring: Reaching 100%
Certain measures are “topped out”—scaled to perfection.
Points Available for a Topped Out Quality Measure (Example) 
What Is Topped Out?
If it is possible to perform a certain measure 100% of the time, it’s “topped out.” A topped out measure requires perfection to earn the full score.
Measure ID
Submission Method
Decile 3 4 5 6 7 8 9 10
Topped Out
225
Claims --
100 NO
Registry/ CDR
YES
Quality Reporting in a MACRA World
May 2017

20. Measures with No Benchmark
Some measures have not had enough historical data submitted to create benchmarks.
Measures with no benchmark will be calculated by CMS based on 2017 performance data if at least 20 reporting clinicians or groups meet the criteria to contribute measures.
If no measure can be calculated then the measure will receive 3 points.
Examples: Measure 405, 406, 436, and many QCDR specific measures.
Quality Reporting in a MACRA World
May 2017

21. Bonus Points
Three types of bonus points are available for Quality Reporting:
Reporting more than 1 outcome measure (+2 pts)
Reporting additional high priority measures (+1 pt)
Using ‘end to end electronic reporting’ (+1 pt per measure)
Quality Reporting in a MACRA World
May 2017

22. Divide by Total Possible Quality Score Equals (out of 100)
Sample Quality Scores #
Perf %
Method
Points 76
96%
Registry 4
145
95%
7.7
146 1%
5.5
195
94%
4.9
225
99% 3
405 2%
28.1 #
Perf %
Method
Points 76
96%
Claims
4.5
145
95%
6.9
146 1% 3
195
94%
5.7
225
99% 4
405 2%
27.1
Red: high priority, bonus eligible (additional after 1st high priority measure)
Points
Bonus
Points Earned
Divide by Total Possible
Quality Score Equals (out of 100)
Registry
28.1 3
31.1 60 52
Claims
27.1
30.1 50
Quality Reporting in a MACRA World
May 2017

23. Sample MIPS Composite Score (Non-Patient Facing or Hospital Based)
Assume full 40 points for Improvement Activities
Registry
Score
X Weight
equals
Quality 52
0.85
44.2 IA
100
0.15 15
Total score
59.2
Claims
Score
X Weight
equals
Quality 50
0.85
42.5 IA
100
0.15 15
Total score
57.5
Quality Reporting in a MACRA World
May 2017

24. How your score impacts your payment
Budget neutrality adjustment: Scaling factor up to 3x may be applied to upward adjustment to ensure payout pool equals penalty pool.
Registry
Score
X Weight
-4% 3
Neutral
(Performance Threshold)
4-100
+4%
(adjusted)
70+
.5-10%
Additional for High Performers
RVU Value x MPFS Conversion Factor x MIPS Adjustment Factor = Medicare Payment
Quality Reporting in a MACRA World
May 2017

25. Wrap Up Am I in an ACO? If yes, my MIPS score = ACO MIPS score
What is my strategy- avoid negative adjustment, try for some bonus money, be a high performer? (Scores are made public.)
Do I have someone developing and implementing my strategy?
Am I submitting as a Group or Individual?
What method will I use to submit my Quality measures?
Which measures am I going to pick? (topped out, no bench mark)
Can I pick measures that will allow for bonus points?
Use past performance to predict MIPS score.
Have I been scored on the All Cause Readmission measure? (QRUR)
Should I consider trying to submit ACI measures?
Quality Reporting in a MACRA World
May 2017

26. Resources https://qpp.cms.gov/ Education & Tools Page Radiology QCDRs
2017 Quality Benchmarks
List of Qualified Registries
List of Qualified Clinical Data Registries is not yet posted
Instructions to get an EIDM account
Radiology QCDRs
ACR
SaferMD
MSN
Quality Reporting in a MACRA World
May 2017

27. Questions Susan Hollabaugh RadNet
VP, Healthcare Regulatory Analysis and Conformance
571‑330‑7423
Quality Reporting in a MACRA World
May 2017