MIPS Improvement Activities: Building Blocks for Value and Quality Care

MIPS Improvement Activities: Building Blocks for Value and Quality Care

Agenda Basics of MIPS MIPS 2017 The MIPS-Medicaid MU relationship Improvement activities as building blocks Improvement Activity Examples Utilizing CMH strengths

The Future of Medicare Value-Based Payment Reform

APMs-Advanced Alternative Payment Models Medicare Shared Savings Program ACOs- Track 2 Medicare Shared Savings Program ACOs- Track 3 Be exempt from MIPS reporting Earn 5% Medicare incentive payment Next Generation ACO Model Comprehensive ESRD Care Model Oncology Care Model OCM CPC+ CMS expanding eligible APMs for 2018

Why MIPS?

Performance: The first performance period opens January 1, 2017 and closes December 31, 2017. During 2017, record quality data and how you used technology to support your practice Send in performance data: To potentially earn a positive payment adjustment under MIPS, send in data about the care you provided and how your practice used technology in 2017 to MIPS by the deadline, March 31, 2018. Feedback: Medicare gives you feedback about your performance after you send your data. Payment: You may earn a positive MIPS payment adjustment for 2019 if you submit 2017 data by March 31, 2018

Payment Adjustments CMS always uses a 2 year look-back method

Who is Eligible? Physician Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist What that means for CMHs? Payment adjustments likely to be minor until 2021 Social workers and psychologists likely to become eligible clinicians in program year 2019

Individual vs. Group Reporting If clinicians participate as a group, they are assessed as group across all 4 MIPS performance categories Why does this matter?

Low-Volume Threshold Clinicians billing Medicare Part B up to $30,000 in allowed charges or providing care for less than 100 Part B patients in a year Low-volume threshold will be applied at individual clinical level (national provider identification (NPI)/tax identification number (TIN) for those reporting individually and group practice (TIN) level for group reporting. A clinician may qualify for exclusion at the individual level (NPI/TIN) but if clinician is part of a group that does not meet criteria, he will be required to participate in MIPS as a group Expect definition of Low-Volume Threshold to change for 2018 What that means for CMHs? Most likely will report ECs as individuals for 2017 and 2018 Will want to consider reporting as a group in 2019

MIPS MIPS is complicated rule and everyone is still learning CMS will need to provide further guidance and clarification Takeaway-MIPS is doable in 2017 if: You are currently doing Meaningful Use You are currently doing PQRS

Starting Point-Assess What You Do (or Don t Do Now) MIPS Questionnaire General Eligible Clinicians Motivation Practice Demographics Quality Measures PQRS Status Initial Selection of Possible Measures Types of Measures Planning Advancing Care Information MU Status CEHRT Obstacles Registry Participation Improvement Activities Initial Selection Cost Review status of current reports

MIPS Categories

MIPS Score Components-2017-2019

Quality Replaces PQRS

Quality Report at least 6 quality measures Or report on a specialty measure set Must include 1 outcome measure For Group Reporting: Registration usually takes place from April-June of program year Groups using the web interface must report on 15 quality measures for a full year

Quality Scoring Each quality measure is assigned a possible 10 quality points based upon the percentile-basis performance of the measure relative to national peer benchmarks. If reporting six measures, 60 quality points available In addition to the six quality measures, CMS calculates either two (for individual clinicians and groups with less than 10 clinicians) or three (for groups with 10+ clinicians) population (claims-based) quality measures Additional 10 or 20 quality points available depending on number of clinicians in the group

Quality-Scoring For example, if a single PQRS measure has a 62% measure rate that is better than 60% of peers reflected in the benchmark, then that measure would earn seven out of 10 possible points. Benchmark Decile Sample Quality Measure Benchmarks Possible Points with 3- Point Floor Benchmark Decile 1 0.0-9.5% 3.0 1.0-1.9 Benchmark Decile 2 9.6-15.7% 3.0 2.0-2.9 Benchmark Decile 3 15.8-22.9% 3.0-3.9 3.0-3.9 Benchmark Decile 4 23.0-35.9% 4.0-4.9 4.0-4.9 Benchmark Decile 5 36.0-40.9% 5.0-5.9 5.0-5.9 Benchmark Decile 6 41.0-61.9% 6.0-6.9 6.0-6.9 Benchmark Decile 7 62.0-68.9% 7.0-7.9 7.0-7.9 Benchmark Decile 8 69.0-78.9% 8.0-8.9 8.0-8.9 Benchmark Decile 9 79.0-84.9% 9.0-9.9 9.0-9.9 Possible Points Without 3-Point Floor Benchmark Decile 10 85.0%-100% 10 10

Quality Scoring If all eight measures earned seven points each, then the total points would be 8 x 7 = 56 out of a possible 80 points, or a 56/80 = 70%. As the Quality category for the CY2017 performance year has a weight of 60%, then a quality score of 70% would result in the Quality category contributing 70% x 60% x 100 = 42 points to the clinician s overall MIPS Final Score.

Quality Reporting Bonus Points MIPS also provides additional paths to achieve a quality score of 100% by granting bonus points for certain quality reporting activities. Up to 10% for submitting high priority measures Up to 10% for end-to-end electronic reporting Total bonus points are capped at 10% of the denominator of the quality score

Cost No reporting requirement Clinicians assessed on Medicare claims data Based on episodic costs 0% of final score in 2017 CMS will still provide feedback on how you performed in this category in 2017, but it will not affect your 2019 payments.

Cost-Example of Episode Cost Measure Group Major Depressive Disorder F32 Major Depressive Disorder F320 Major Depressive Disorder F321 Major Depressive Disorder F322 Major Depressive Disorder F323 Major Depressive Disorder F324 Major Depressive Disorder F325 Major Depressive Disorder F329 Major Depressive Disorder F33 Major Depressive Disorder F330 Major Depressive Disorder F331 Major Depressive Disorder F332 Major Depressive Disorder F333 Major Depressive Disorder F334 Major Depressive Disorder F3340 Major Depressive Disorder F3341 Major Depressive Disorder F3342 Major Depressive Disorder F339 Major Depressive Disorder, Single Episode Major Depressive Disorder, Single Episode, Mild Major Depressive Disorder, Single Episode, Moderate Major Depressive Disorder, Single Episode, Severe Without Psychotic Features Major Depressive Disorder, Single Episode, Severe With Psychotic Features Major Depressive Disorder, Single Episode, In Partial Remission Major Depressive Disorder, Single Episode, In Full Remission Major Depressive Disorder, Single Episode, Unspecified Major Depressive Disorder, Recurrent Major Depressive Disorder, Recurrent, Mild Major Depressive Disorder, Recurrent, Moderate Major Depressive Disorder, Recurrent Severe Without Psychotic Features Major Depressive Disorder, Recurrent, Severe With Psychotic Symptoms Major Depressive Disorder, Recurrent, In Remission Major Depressive Disorder, Recurrent, In Remission, Unspecified Major Depressive Disorder, Recurrent, In Partial Remission Major Depressive Disorder, Recurrent, In Full Remission Major Depressive Disorder, Recurrent, Unspecified

Advancing Care Information (ACI) The Advancing Care Information score is the combined total of the following three scores: In order to receive the 50% base score, MIPS eligible clinicians must submit a yes for the security risk analysis measure, and at least a 1 in the numerator for the numerator/denominator of the remaining measures. Example: If a MIPS eligible clinician receives the base score (50%) and a 40% performance score and no bonus score, they would earn a 90% Advancing Care Information performance category score. When weighted by 25% (ACI Weighted score), this would contribute 22.5 points to their overall MIPS final score. (90 X.25 = 22.5).

ACI Advancing Care Information Transition Objective Protect Patient Health Information Electronic Prescribing Patient Electronic Access Coordination of Care Through Patient Engagement Health Information Exchange 2017 Advancing Care Information Transition Measure* Security Risk Analysis E-Prescribing Provide Patient Access Patient Specific Education View, Download, or Transmit (VDT) Secure Messaging Required/ Not Required for Base Score (50%) Required 0 Required 0 Performance Score (Up to 90%) Required Up to 20% 2017 Up to 10% - 2018 Not Required Up to 10% NotRequired Not Required Up to 10% Up to 10% Patient-Generated Health Data Not Required Up to 10% - 2018 Send a Summary of Care Required Up to 20% 2017 Up to 10% - 2018 Request/Accept Summary of Care Clinical Information Reconciliation Required Up to 10% - 2018 Not Required Up to 10% - 2018 Reporting Requirement Yes/No Statement Numerator/ Denominator Numerator/ Denominator Numerator/ Denominator Numerator/ Denominator Numerator/ Denominator Numerator/ Denominator Numerator/ Denominator Medication Reconciliation Not Required Up to 10% - 2017 only Numerator/ Denominator

Advancing Care Information Transition Objective 2017 Advancing Care Information Transition Measure* Required/ Not Required for Base Score (50%) Performance Score (Up to 90%) Reporting Requirement Public Health and Clinical Data Registry Reporting Immunization Registry Reporting Syndromic Surveillance Reporting NotRequired Not Required 0 or10% Bonus- 2017 & 2018 Yes/No Statement Yes/No Statement Electronic Case Reporting Public Health Registry Reporting Not Required Not Required Bonus-2018 only Bonus-2018 only Yes/No Statement Yes/No Statement ACI Clinical Data Registry Reporting Not Required Bonus-2018 only Yes/No Statement Specialized Registry Not Required Bonus-2017 only Bonus up to 15% Report to one or more additional public health and clinical data registries beyond the Immunization Registry Reporting measure Report improvement activities using CEHRT 5% bonus 10% bonus Yes/No Statement Yes/No Statement

Performance Rate Score Objectives Measures 90-100% ACI Performance Scoring Patient Electronic Access Patient Access 80-90% 91% 70-80% Patient Specific Education Coordination of Care Through Patient Engagement VDT Secure Messaging Patient- Generated Health Data Health Information Exchange Patient Care Record Exchange Request/ Accept Patient Care Record 60-70% 68% 64% 50-60% 40-50% 30-40% 20-30% 10-20% 13% 0-10% 5% 6% 4% Percentage Points Earned 6.8% 9.1%.05% 0.6%.04% 1.3% 6.4% Total Performance Score 24.2% Clinical Information Reconciliation

Calculating the Final Score Under MIPS Final Score= Clinician Quality performance category score x actual Quality performance category weight Clinician Cost performance category score x actual Quality performance category weight Clinician Improvement Activities performance category score x actual Improvement Activities performance category weight Clinician Advancing Care Information performance category score x actual Advancing Care Information performance category weight

Improvement Activities Attest to participation in activities that improve clinical practice Clinicians choose from 90+ activities under 9 subcategories

Improvement Activities Special consideration for:

MIPS Scoring for Improvement Activities Total points = 60 Activity Weights Medium = 10 points High = 20 points Full credit for clinicians in a patient-centered medical home, Medical Home Model, or similar specialty practice

MIPS 2017 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. Full: If you submit a full year of 2017 data to Medicare, you may earn a positive payment adjustment.

Scoring Creates 100-point system to increase and consolidate financial impacts Ranks peers nationally, and reports scores publicly 2017 weightings put 85% in the Quality and ACI categories Resource Use is 0 for 2017, but will be scored in 2018 and beyond 15 25 60 POINTS POINTS POINTS 0 POINTS Resource Use (Cost) Clinical Practice Improvement Activities Advancing Care Information (Meaningful Use) Quality (PQRS/VBM)

ACI-2017 In 2017, there are two measure set options for reporting: Advancing Care Information Objectives and Measures 2017 Advancing Care Information Transition Objectives and Measures The option you ll use to send in data is based on your Certified EHR Technology edition To report on the first measure set requires 2015 Edition technology 2014 CEHRT may be used to report on the 2017 measure set

MIPS Scoring for Improvement Activities 2017 Requirement: Total points = 40 Activity Weights Medium = 10 points High = 20 points Alternative Activity Weights Medium = 20 points High = 40 points For clinicians in small, rural, and underserved practices or with non-patient facing clinicians or groups Full credit for clinicians in a patient-centered medical home, Medical Home Model, or similar specialty practice

Calculating the Final Score Under MIPS (2017) Quality 5 points x 8 measures=40 points Improvement Activities ACI 40/80 possible points = 50% [50% x 60% (MIPS weight)] x 100= 30 points Bonus- Up to 6 bonus points possible 40 points out of 40 possible points = 100% [100% x 15% (MIPS weight)] x 100 = 15 total points 74.7points/100 possible points=74.7% [74.7% x 25% (MIPS weight)] x 100 = 18.66 total points Final Score 36 + 15 + 18.66= 69.66Points = 36 total points

Transition Year 2017 Final Score Payment Adjustment 70 points Positive adjustment Eligible for exceptional performance bonus-minimum of additional 0.5% 4-69 points Positive adjustment Not eligible for exceptional performance bonus 3 points Neutral payment adjustment 0 points Negative payment adjustment of -4% 0 points=does not participate

Medicaid EHR Incentive Program and MIPS Separate program from MIPS The Medicaid EHR Incentive Program will provide incentive payments to providers for a total of 6 year, with 2016 the last year to begin the program Provider began program in 2012, would receive incentives through reporting year 2017 Provider began program in 2016, would receive incentives through reporting year 2021 In 2017, providers will be attesting to Modified Stage 2 Very similar to 2016, with two objectives having higher thresholds

Medicaid EHR Incentive Program and MIPS Providers still retaining eligibility in the Medicaid EHR program who also bill Medicare Part B services may/will attest for both the Medicaid EHR program and MIPS Medicaid meaningful use objectives may/may not align with the MIPS Advancing Care Objectives Requires attestation through two separate reporting mechanisms

Improvement Activities The key to moving towards value and quality

What is an Improvement Activity An activity that stakeholders identify as improving clinical practice or care delivery Focuses on CMS strategic goals to use a patient-centered approach to program development that leads to better, smarter, and healthier care

Improvement Activities CMS makes it clear that the first year will be the easiest year for Improvement Activities. They hope to create baseline requirements the first year and then build more stringent requirements in future years, laying the groundwork for expansion towards continuous improvement over time In future years, CMS proposes to assign scores based on providers performance or improvement on CPIAs

Improvement Activities Improvement activities are foundational to MIPS (and/or MU) Formal, systematic approach to: Analysis of practice performance Efforts to improve performance Many times we fly by seat of out pants due to lack of time/resources Reality Check: It takes planning to succeed It takes time to strategize and implement performance improvements, including partnerships and technology. This gives us opportunity to lay and document groundwork for real improvement (and get credit for it)

Improvement Activities-Getting Started 1. Choose measures to maximize score Relevant to your scope of practice Can demonstrate improvement Compliments other current work Doable

Improvement Activities-Getting Started 2. Plan implementation Data sources/technology Patient outreach Workflow integrate don t layer Staff training Community partners

Improvement Activities-Getting Started 3. Documentation Who How When

Sample Improvement Activities

Track Patients Referred to Specialist through the Entire Process (Medium) Background High fragmentation of health care delivery systems Referral tracking provides opportunity to improve communication and coordination between all providers Many obstacles to achieving referral tracking: Volume of referrals EHR inefficiencies Lack of staff Cumbersome processes Challenging population that often does not keep appointments

Track Patients Referred to Specialist through the Entire Process (Medium) Purpose Specialist receives necessary information for referral appointment in a timely manner Increased percentage of patients showing for referral appointment Documentation is received from the specialist and integrated into the patient s EHR chart Decrease number of patients who fall through the cracks

Track Patients Referred to Specialist through the Entire Process (Medium) Improvement Activity aligns with the following MIPS or Medicaid MU requirements Advancing Care Information Objectives: Health Information Exchange Objective Send a Summary of Care Record Request/accept Summary of Care Record Clinical Information Reconciliation (2017-Medication Reconciliation) Quality Measure MU MU-Stage 3 MU Closing the Referral Loop; Receipt of Specialist Report (CMS 50v5) (High) MU

Track Patients Referred to Specialist through the Entire Process (Medium) Plan Details Document baseline data Assign project coordinator responsible for implementation of improvement activity Confirm Names/Roles of staff included in process Provide education on: How to document referral (in EHR or manually) How to create and electronically exchange the summary of care record How to run referral reports or review of manual documentation How to integrate specialist s documentation into EHR How to perform and document Clinical Information Reconciliation How to close loop of referral process Monitor reports/results monthly

Track Patients Referred to Specialist through the Entire Process (Medium)

Provide 24/7 access to eligible clinicians or groups who have real-time access to patient's medical record Improvement Activity aligns with the following MIPS or Medicaid MU requirements: - Potential impact on episode cost - Quality Measures (some of them) Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (CMS 2) Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (CMS 177) Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (CMS 161)

Provide Peer-led support for self-management Improvement Activity aligns with the following MIPS or Medicaid MU requirements: - Potential impact on episode cost - Advancing Care Information Objectives: Patient Portal View, Download, or Transmit Secure Messaging Patient-generated Health Data - Quality Measure Anti-Depressant Medication Management (CMS 128 v5)

Collection & Follow-up on Patient Experience & Satisfaction Data on Beneficiary Engagement, including Development of Improvement Plan (High) Improvement Activity aligns with the following MIPS or Medicaid MU requirements Will Enhance Score on the Following Advancing Care Information Objective: Coordination of Care Through Patient Engagement View, Download, or Transmit Secure Messaging MU Patient-generated Health Data Quality Measure MU MU-2018 CAHPS for PQRS (MIPS) Clinician/Group Survey (NQF: 0006 & 0005) (High)

How do these measures relate to a Behavioral Health Agency? What do you think might be easy to implement? What measures might be more challenging? What measures do you think will lead to improved quality? What could lead to more efficient services?

Final Thoughts MIPS is doable Select/empower a MIPS team Complete the MIPS Questionnaire Review all know data Meaningful Use objective percentages PQRS Feedback reports QRUR reports

Resources CMS Quality Payment Program Resources https://qpp.cms.gov/ CMS-MIPS Scoring Methodology Overview https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value- Based-Programs/MACRA-MIPS-and-APMs/MIPS-Scoring-Methodology-slide-deck.pdf Introduction to the QPP and MIPS-HealthIT https://www.healthit.gov/facas/sites/faca/.../hitjc_qpp_review_2016-12-06.pptx SA Ignite-The ABCs of MIPS Webinar Series http://www.saignite.com/resources/hitech-abc-of-mips-webinar National Council for Behavioral Health-MACRA Resources https://www.thenationalcouncil.org/macra/ American Psychiatric Association-Payment Reform Toolkit https://www.psychiatry.org/psychiatrists/practice/practice-management/codingreimbursement-medicare-and-medicaid/payment-reform

Thank You Cindy Buege, CPHIMS, CHPS, Project Manager cbuege@mphi.org Krista Hauserman,, LMSW, CAADC, HIT Specialist khauserm@mphi.org