1. Quality Payment Program Overview
Kris Shay, HealthCare Data Systems
Mona Mathews, MA, PMP, MetaStar
Chris Becker, CPHIMS, CPHIT, MetaStar
October 19, 2018

2. Lake Superior Quality Innovation Network
The Lake Superior Quality Innovation Network (Lake Superior QIN) is comprised of three quality improvement organizations:
Stratis Health in Minnesota
MetaStar in Wisconsin
MPRO in Michigan

3. Disclaimer
Content provided in this presentation is based on the latest information made available by the Centers for Medicare & Medicaid Services (CMS) and is subject to change. CMS policies change, so we encourage you to review specific statutes and regulations that may apply to you for interpretation and updates.

4. Objectives
Knowledge on 2018 Merit-Based Incentive Payment System (MIPS)
Orthopaedic requirements for MIPS
Tips and Tricks for participating successfully in MIPS .

5. Quality Payment Program
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
MIPS
Merit-Based Incentive Payment System (MIPS)
Performance-based payment adjustment
Advanced APMs
Advanced Alternative Payment Models (Advanced APM)
Incentive payment for sufficiently participating in an innovative payment model
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS by law to implement an incentive program, referred to as the Quality Payment Program, that provides for two participation tracks:

6. 2018 Year 2 MIPS Eligible Clinicians
Low-volume threshold for 2018 Year 2 changes to INCLUDE MIPS eligible clinicians billing more than $90,000 a year in Medicare Part B allowed charges AND providing care for more than 200 Medicare patients a year.
2017 Year 1
Bill > $30,000 Medicare Part B AND
Provide care to > 100 beneficiaries
2018 Year 2
Bill > $90,000 to Medicare Part B AND
Provide care to > 200 beneficiaries
Revised from overview slides – which listed Non-patient facing clinicians as excluded from MIPS – they are only excluded from ACI
*Voluntary reporting remains an option for clinicians exempt from MIPS

7. QPP Eligibility Look Up Results
MIPS Participation Status Tool
Source:

8. 2018 Reporting Options
Clinicians participating as a group are assessed as a group across all four MIPS performance categories. The same is true for clinicians participating as a Virtual Group.
CMS-QPP-Year-2-Final-Rule-National Provider Call-Slides

9. Focus on MIPS Reporting

10. Merit-Based Incentive Payment System (MIPS)
Four MIPS category scores compiled for
MIPS final score worth up to 100 points
Quality
Improvement Activities
Promoting Interoperability
Cost
Previous Category –
Year
Physician Quality Reporting System (PQRS)
New Category
EHR Incentive Program
Value Based Modifier (VBM)
2018
50 %
15 %
25 %
10 %
2017
60 %
15%
25%
0 %
Replaces PQRS: Maximum score 60
Evolution of previous CMS programs: PQRS, VBM, MU
Report six quality measures* from over 300 quality measures OR measures from Specialty set
Report via Claims, EHR, Registry
Benchmark scores differ between reporting methods
Groups of 25+ can use CMS GPRO Web Interface
Report 14 quality measures*
APMs report quality as a groups
*Measure must meet qualification criteria for all methods
If reporting as a group, combine all EC scores
Lisa
The 2nd path of the QPP is the Merit Based Incentive Payment System or MIPS
CMS has combined the legacy programs of PQRS, EHR incentive payment system and Value- Based Modifier into 1 program, renamed them and added a new category of Improvement Activities.
This screen shows the 4 categories of MIPS which each contribute a certain weight to your MIPS Score. Your MIPS Score is based on the performance year, and impacts your payment 2 years later for Medicare Part B fee for service
For 2017 performance year:
Quality – accounts for 60% of the MIPS score
Advancing Care Information accounts for 25% of your score
New category of Improvement Activities accounts for 15% of your score
Cost accounts for 0% of your score, but will be phased in in future years.
Source: CMS Quality Payment Program – Train-the-Trainer

11. Quality Category: 50 percent of MIPS Score in 2018
Earn up to 60 Quality Category points
Scored on the highest six quality measures from 277 measures
May pick from specialty set
Must include at least one outcome or high priority measure
Earn three to 10 category points for measures with benchmarks
Earn up to seven points for six measures - if “topped out*” two or more years*
Must meet data completeness criteria (2018 increased to 60 percent)
2018 Earn one point for reporting if data completeness not met
Small practices still earn three points
Bonus points for reporting end to end electronically (electronic clinical quality measure (eCQM))
Bonus points for reporting additional outcome or high priority measures
The six topped out measures include the following:
Perioperative Care: Selection of Prophylactic Antibiotic-First or Second Generation Cephalosporin. (Quality Measure ID: 21)
Melanoma: Overutilization of Imaging Studies in Melanoma.(Quality Measure ID: 224)
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients). (Quality Measure ID: 23)
Image Confirmation of Successful Excision of Image-Localized Breast Lesion. (Quality Measure ID: 262)
Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT) Imaging Description (Quality Measure ID: 359)
Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy (Quality Measure ID: 52)
*Topped out measures have little room for improvement

12. Examples of Orthopedic Quality Measures
Closing the referral loop Documentation of current medications in the medical record Functional status assessment for total knee replacement Body Mass Index (BMI) screening and follow up plan Pain assessment and follow up

13. Cost: 10 percent of MIPS Score in 2018
Category Performance Score included in composite MIPS score starting in 2018
TWO measure scores are averaged (or any one available)
Medicare Spending per Beneficiary (MSPB)
Total per capita cost measures
Category score weight will increase to 30 percent by 2021
No data submission required; Calculated from administrative claims if meet case minimum of attributed patients
Benchmark calculated using current year performance
New: Scoring Improvement Bonus up to one percentage point
Based on statistically significant changes at the measure level
.Lisa
Cost is not scored in 2017 and will be phased in either in 2018 or 2019
No data submission – calculated automatically from Adjudicated Part B claims

14. Improvement Activities: 15 percent of MIPS Score 2017-2018
Maximum Category score 40 points
Help participants prepare to transition to APMs and Medical Home Models. Additional activities available in 2018, some changed
Engage in up to four activities for at least 90 days
Medium activity = 10 points
High activity = 20 points
Earn PI category Bonus points for using CEHRT for some IA
Report by simple Yes/No attestation
Special Scoring: Double points: clinicians in small underserved or rural settings, and non-patient facing clinicians/groups
Double points for small, rural, underserved, and non-patient facing clinicians/groups
Full credit for PCMH, MHM (MN model counts)
APMs – choose activities based on model criteria
*We have defined practice sites as the practice address that is available in PECOS
*Changes: including credit for using Appropriate Use Criteria (AUC) through a qualified clinical support mechanism for all advanced diagnostic imaging services ordered.

15. Possible Improvement Activities in Orthopedics
Annual registration in the Prescription Drug Monitoring Program (PDMP) Anticoagulant Management Improvements i.e.: Patients being managed by an anticoagulant management service Consultation of the PDMP Implementation of use of specialty report back to referring clinician or group to close the referral loop

16. Promoting Interoperability: 25 percent of MIPS Score in 2018
Maximum Category score 100 of 155 possible points
Earn up to 25 MIPS points
2018: May use either 2014 or 2015 Certified EHR Technology (CEHRT) (or combination)
10 percent bonus for using only 2015 CERHT
Base measures, required for any score in this category
Earn 50 points
Four base measures for 2014 CEHRT, five for 2015 CEHRT; some measures also earn performance scores
Exclusions available for two base measures: e-Prescribing and Health Information Exchange: Send Summary of Care
Performance measures Optional
Earn up to 90 points
Seven for 2014 CEHRT, nine for 2015 CEHRT
Mention ACI Exclusions for
Hospital-based, Non-patient facing, and some EC types: NP, CNS, CRNA, PA

17. 2014 vs 2015 Certified EHR
Four Base Measures = 50 points Seven Performance Measures
Earn up to 10 points each
Two worth 20 points each
Five Base Measures = 50 points Nine Performance Measures
Earn up to 10 points each
2015 CEHRT
MEASURE NAME
Security Risk Analysis (Base)
e-Prescribing (Base)
Send Summary of Care (Base)
Request/Accept Summary of Care (Base)
Provide Patient Access (Base)
Clinical Information Reconciliation
Patient-generated Health Data
Immunization Registry Reporting
Patient-Specific Education
Secure Messaging
View, Download, or Transmit (VDT)
Clinical Data Registry Reporting
Public Health Registry Reporting
Electronic Case Reporting
Syndromic Surveillance Reporting
2014 CEHRT
MEASURE NAME
Security Risk Analysis (Base)
e-Prescribing (Base)
Send Summary of Care (Base)
Provide Patient Access (Base)
Immunization Registry Reporting
Medication Reconciliation
Patient-Specific Education
Secure Messaging
View, Download, or Transmit (VDT)
Specialized Registry Reporting
Syndromic Surveillance Reporting
2016
Opportunity to reach 155 points with bonuses, but maximum category score is 100

18. Reporting Scenarios of Orthopaedics

19. Scenario One Background Reporting Options Solo Practice Surgeon
Eligible Clinician (exceeds low volume threshold)
Must report to avoid a negative penalty
Does not utilize an EHR
Reporting Options
Needs to obtain 15 MIPS Points to remain Neutral
Could attest to Improvement Activities
Report Quality Category via claims or registry
Note: Practices with 15 or less clinicians get some special scoring

20. Solo Surgeon Reporting with No EHR
Clinician decides that she does not want to pay for a registry and go through the trouble of doing chart reviews to populate the registry
Finds out that billers have been submitting some “G” Codes for Medication Reconciliation and Body Mass Index Screening but they did not meet the 60 percent data completeness for quality
Attests to using the Prescription Drug Monitoring Program (PDMP)

21. Score for this Solo Clinician
One Improvement Activity
Two Quality Measures
Five free points for being a small practice
Small Practices receive double points for Improvement Activities and a minimum of three points for quality measures
Source: Stratis Health MIPS Estimator

22. Scenario Two Background Reporting Options
Orthopaedics Group Practice with 16 Eligible Clinician Types
Has EHR through the local hospital
Two of the clinicians exceed the low Volume Threshold
The remaining 14 are eligible at the group level but not individually
Reporting Options
Group Reporting
Individual Reports (2 mandatory and 14 voluntary)

23. Scores for Mandatory Clinicians
William White
Patricia White
Source: Stratis Health MIPS Estimator

24. Group Score
Source: Stratis Health MIPS Estimator

25. Group versus Individual Reports
Individual Report – The individual clinicians will receive a payment adjustment Group report – All eligible clinician types in the group will receive a payment adjustment In this example, the group score was greater than either of the mandatory reporters so if a group report was submitted, they would receive the higher of the two scores.

26. Important Information About the Scenarios
Did not give any points for cost or complex patient bonus The scores were calculated based on the most current benchmarks (some benchmarks will be recalculated during the performance year)

27. Resources
Stratis Health MIPS Estimator Quality Payment Program Website:

28. Questions? Kris Shay – HealthCare Data Systems
Mona Mathews, MA, PMP – MetaStar
Chris Becker, CPHIMS, CPHIT – MetaStar

29. This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-WI-D