mips simplified scoring

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MIPS SIMPLIFIED SCORINGStrategic Healthcare Partners, LLC

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MEMORABLE FACTOIDS

1. ≈95% of providers will participate in MIPS2. MIPS is budget neutral. Losers’ penalties pay winners’ bonus3. Congressional Lawmakers sought to “simplify” physician

benchmarking4. AHIP & CMS already agreed to harmonize quality metrics5. MIPS scores will be publicly available6. An Advanced Alternative Payment Model (APM) is a generic term to

describe 2-sided risk based arrangementsApril 2015

• MACRA passed via bipartisan support

April 2016

• Proposed Rule Released

November 2016

• Final Rule Released

January 1, 2017

• Reporting Year 1 Begins

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ACRONYM GUIDE ACI – Advancing Care Information (Formerly Meaningful Use) AHIP – American Health Insurance Plans APM – Advanced Alternative Payment Model CCM – Chronic Care Management (CPT 99490) CERHT – Certified Electronic Health Record Technology CPIA – Clinical Practice Improvement Activities CPOE – Computerized Provide Order Entry (E-Prescribing) CPS – Composite Performance Score HIE – Health Information Exchange MACRA – Medicare Access and CHIP Reauthorization Act of 2015 MSPB – Medicare Spending Per Beneficiary MSSP – Medicare Shared Savings Program PCMH – Patient Centered Medical Home SDOH – Social Determinants of Health TCM – Transitional Care Management (CPTs 99495-6) QPP - Quality Payment Program QCDR – Qualified Clinical Data Registry

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MACRA STATUS UPDATE 9/8/16

1Test Program: Submit

any data to avoid negative payment

adjustment

2Participate for part of

year for a “small positive adjustment”

3 Participate for the entire year for a

“moderate positive adjustment”

4Avoid MIPS via

Advanced Alternative Payment Model (APM)

CMS announced 4 Options for MIPS

Key Take Away: If you can, participate for the entire year.

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≈95% PROJECTED TO PARTICIPATE IN MIPS

Solo2-9 physicians

10-24 physicians 25-99

physicians 100+ physicians

0%10%20%30%40%50%60%70%80%90%

MIPS Estimated Economic Impact 2019

% Eligible Clinicians MIPS Penalty % Eligible Clinicians MIPS Bonus

*Estimations prior to recent update nullifying negative penalties in 2019

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Category Formerly Known As:

Year 1 Weight

Scoring Methodology

Quality PQRS 50% • Each measure 1-10 points compared to historical benchmark

• 0 points for non-reported measure• Bonus Points available• Measures are averaged for total

categorical scoreAdvancing Care Information

Meaningful Use

25% • Base score of 50% points achieved by reporting at least one unique patient for each measure

• Performance score of up to 80% points• Public Health Reporting Bonus Point• 100% points = Full Credit

Clinical Practice Improvement Activities

N/A 15% • 10 Point “medium weight” activities & 20 Point “high-value” activities available

• 60 Points = Full Credit

Resource Use Value-Modifier

10% • Similar Scoring to Quality Category• No Reporting Necessary!

QualityAdvancing

Care Information

Clinical Practice

Improvement Activities

Cost:Resource Utilization

Key Take-Away: Quality & ACI Take priority.

MIPS COMPOSITE SCORE SUMMARY

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QUALITY PERFORMANCE

Each measure is converted to a decile point scale

(1-10)

Zero points for a non-reported measure

Bonus points

Total Point

sTotal

PointsTotal

Possible Points

QualityComposite Performance Score

QualityAdvancing

Care Information

Clinical Practice



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Decile 1 2 3 4 5 6 7 8 9 10Possible Points

1.0-1.9

2.0-2.9

3.0-3.9

4.0-4.9

5.0-5.9

6.0-6.9

7.0-7.9

8.0-8.9

9.0-9.9

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QUALITY PERFORMANCE

• CMS publishes deciles based on national performance in baseline period• Eligible clinician’s performance is compared to baseline• If performance on a measure is clustered together (i.e. 70% of respondents are within

3 deciles, the midpoint decile will be assigned to all providers in this cluster)

Decile 1 2 3 4 5 6 7 8 9 10Possible Points

1.0-1.9

2.0-2.9 3.0-3.9 4.0-4.9 5.0-5.9 6.0-6.9 7.0-7.9 8.0-8.9 9.0-9.9 10

% of Providers

0% 2% 3% 5% 10% 80%

All 80% of these providers will receive the midpoint

decile of 8 points

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QUALITY PERFORMANCE- BONUS POINTS

• Earn up to a possible 10% “extra credit” in bonus points• 1 bonus point for other “high priority” measures (up

to 5%)• 1 bonus point for each measure reported using CEHRT

(up to 5%)• 2 bonus points awarded for additional

outcome/patient experience• Not available for claims Quality

Advancing Care

Information

Clinical Practice



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Measure Measure Type

# of Cases

Points Based on Performance

Total Possible Points (10 x Weight)

Quality Bonus Points for High Priority

Quality Bonus Points for EHR

Measure 1 Outcome Measure using CEHRT

20 4.1 10 0 (Required) 1

Measure 2 Process using CEHRT

21 9.3 10 1

Measure 3 Process using CEHRT

22 10 10 1

Measure 4 Process 50 10 10

Measure 5 High Priority-Patient Safety

43 8.5 10 1

Measure 6 (Missing)

Cross-Cutting

N/A 0 10

Acute Composite

Admin. Claims

10 Not scored: below minimum sample size

Chronic Composite

Admin. Claims

20 6.3 10

Total Points

All Measures

N/A 48.2 70 1 3

QUALITY PERFORMANCESCORINGEXAMPLE

QualityAdvancing

Care Information

Clinical Practice


Cost:Resource UtilizationKey Take-Away: Know your measures. Include 1 Outcome & 1 Cross-

Cutting Measure. Consult CMS’ Core Set Measures.

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QUALITY PERFORMANCE

52.2 Total Points

70 Possible Points

74.6% Quality Score

48.2 Points

1 Bonus Point for

high priority measure

3 bonus points for

CEHRT Reporting

52.2 Total

Points

QualityAdvancing

Care Information

Clinical Practice



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ADVANCING CARE IMPROVEMENT

Base Score Performance Score

Bonus Point

Composite Score

Represents 50

Points of ACI Score

Represents 80

Points of ACI Score

Up to 1 Point of

ACI Score

100 Points =

Full Credit in ACI

Category

QualityAdvancing

Care Information

Clinical Practice



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ACI BASE SCORE

Protect PHI(Required)

CPOE(E-Prescribing)

Patient Electronic

Access(Patient Portal)

Coordination of Care Through

Patient Engagement

Health Information Exchange

Public Health/Clinical Data Registry

Reporting (Required)

To receive full credit of the base score,

physicians will need to report one unique

patient in each category

QualityAdvancing

Care Information

Clinical Practice



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ACI BASE SCORE PROPOSED EXAMPLES

Protect PHI

• Security Analysis (Required)

Electronic Prescribing

• CPOE

Public Health and Clinical Data Registry

Reporting• Immunization Registry Reporting (Required)

• Syndromic Surveillance Reporting (Optional)

• Electronic Case Reporting (Optional)

• Public Health or Clinical Data Registry Reporting (Optional)

Coordination of Care Through

Patient Engagement

• View, Download, and Transmit (VDT)*

• Secure Messaging*

• Patient-Generated Health Data*


• Exchange Information with Other Clinicians*

• Exchange Information with Patients*

• Clinical Information Reconciliation*

Patient Electronic Access

• Patient Access to PHI*

• Patient-Specific Education*

* = Proposed Performance Score

QualityAdvancing

Care Information

Clinical Practice



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ACI PERFORMANCE SCORE

Patient Electronic

Access

Coordination of Care Through Patient

Engagement


Physicians will be proportionally scored against their peers in

terms of patient engagement with these objectives

QualityAdvancing

Care Information

Clinical Practice


Cost:Resource UtilizationKey Take-Away: Get creative to encourage patients to utilize

patient portal.

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CLINICAL PRACTICE IMPROVEMENT ACTIVITIES: SUMMARY

90+ proposed activities categorized as “high” 20 point activities or “medium” 10 point categories

Full credit is achievement of 60 points Patient-Centered Medical Home (PCMH)

guarantees full credit APM participation receives a minimum of

half credit

QualityAdvancing

Care Information

Clinical Practice



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CPIA REPORTING OPTIONS

Individual

ReportingAttestation

QCDR

Qualified Registry

Electronic Health Record

Administrative claims (if technically feasible, no submission required)

Group Reporting

Attestation

QCDR

Qualified Registry

Electronic Health Record

CMS Web Interface (Groups of 25+)

Administrative claims (if technically feasible, no submission required)

QualityAdvancing

Care Information

Clinical Practice



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CPIA SUBCATEGORIESExpanded

Practice AccessBeneficiary

Engagement

Population Health

Management

Patient Safety and Practice Assessment

Care Coordination

Participation in an APM,

including a medical home

model

These 6 subcategories proposed in

NPRM

Achieving Health Equity

Emergency Preparedne

ss and Response

Integrated Behavioral & Mental Health

These 3 subcategorie

s are required in

MACRAQuality

Advancing Care

Information

Clinical Practice



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CPIA EXAMPLESExpanded Practice Access

24/7 Access to Care team

Telehealth

Patient Experience used for QI

Projects

Population Health

Management

Participation in systemic

anticoagulation program

Participation in a QCDR

Monitor health

conditions

Care Coordinati

on

Participate in Transforming

Clinical Practice Initiative

Closing the referral loop

Timely HIE with patients & providers

Beneficiary

Engagement

Collect & utilize patient

experience data

Beneficiary Training for

self-management

Patient portalQuality

Advancing Care

Information

Clinical Practice



20 points!

Full Credit = 60 points

10 points!

20

Patient Safety & Assessm

ent

Opioid Management

Use of Surgical

Checklists

STEPS Forward Program

Achieving Health Equity

Timely care for Medicaid

patients

Participate in State

Innovation Model

activities

Screen for SDOH

Emergency

Response

Participate in Disaster

Medical Assistance

teams

Participate in domestic

or international humanitarian

work

Integrated

Behavioral &

Mental HealthCo-location of

mental health

services in clinical settings

Depression Screening

Substance abuse

prevention & treatment

QualityAdvancing

Care Information

Clinical Practice



10 points!

20 points!

Full Credit = 60 points

CPIA EXAMPLES

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CPIA SCORING SUMMARY

50 Total CPIA

Points60

Points83% CPIA Score

QualityAdvancing

Care Information

Clinical Practice



Participate in TCPI

Telehealth

Use of Surgical Checklist

s

Patient Portal

50 Total CPIA

Points 83% x 15% weight for CPIA = 12.5 points

towards MIPS Composite Score

20 PointActivity

10 PointActivity

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CPIA SPECIAL SCORING CONSIDERATIONS

QualityAdvancing

Care Information

Clinical Practice



• Non-patient facing eligible clinicians, small practices (15 or fewer professionals), rural practices, and clinicians in geographic health professional shortage areas:• 1st activity earns 50% of the 60 points• 2nd activity earns 100% of the 60 points

• APM participation automatically earns 50% of the 60 points

• PCMH’s receive 60 points

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RESOURCE UTILIZATION:KEY CHANGES

Value Modifier

• 6 Measures; Total per capita costs for all attributed beneficiaries

• Medicare spending per Beneficiary (MSPB)

• Total per capita cost measures for 4 condition-specific groups (COPD, CHF, CAD, Diabetes)

• Attribution to group practice (TIN)

Proposed MIPS Resource Use Category

• 2 of the 6 VM measures; Total per capita costs for all attributed beneficiaries

• Medicare spending per Beneficiary (MSPB)

• Removes total per capita cost for the 4 condition-specific groups

• Proposes up to 41 other episode-based measures

• Attribution to group (TIN) or individual TIN or NPI

QualityAdvancing

Care Information

Clinical Practice



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RESOURCE UTILIZATION:KEY CHANGES - ATTRIBUTION

Value Modifier

• 2-step process for claims-based measures

Proposed MIPS Resource Use

Category• Expansion of primary

care services to align with MSSPs:• Inclusion of CCM &

TCM coding• Exclusion of nursing

visits occurring in SNFQuality

Advancing Care

Information

Clinical Practice



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RESOURCE UTILIZATION:KEY CHANGES - MSPB

Value Modifier

• MSPB measures care around a hospitalization

• Adjusted for IP DRG & a separate adjustment is applied to specialty composition of group practice

• Minimum of 125 cases to be “reliably” measured

Proposed MIPS Resource Use Category

• Individual cases measured the same

• 2 technical adjustments for MIPS:• Modified individual case

aggregation• Removed specialty adjustment

• Two adjustments make MSPB more at the smaller case volume

• 20 cases is the proposed threshold for episode-groups Quality

Advancing Care

Information

Clinical Practice



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Resource Use

Type of Measur

e

# of Cases

Performance

Measure Performanc

e Threshold

Points Based

on Decile

Total Possible Points

M1 MSPB 20 $15,000 $13,000 4.0 10

M2 Total Per Capita

21 $12,000 $10,000 4.2 10

M3 Episode 1 22 $15,000 $18,000 5.8 10

M4 Episode 2 10 $11,000 $9,000 Below Case

Threshold

N/A

M5 Episode 3 0 N/A N/A No attributed

cases

N/A

M6 Episode 4 45 $7,000 $10,000 8.3 10

Total 22.3 40

RESOURCE USE SCORING SAMPLE

QualityAdvancing

Care Information

Clinical Practice



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RESOURCE USE SCORINGEach

measure is

converted to decile points (1-

10)

(Only Includes

Case Volumes

>20)

Total Points

22.3 points

40 possible points

55.8%Resourc

e Use Score

QualityAdvancing

Care Information

Clinical Practice



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Category

Formerly Known As:

Year 1 Weight

Scoring Methodology

Quality PQRS 50% • Each measure 1-10 points compared to historical benchmark

• 0 points for non-reported measure• Bonus Points available• Measures are averaged for total

categorical scoreAdvancing Care Information

Meaningful Use

25% • Base score of 50% points achieved by reporting at least one unique patient for each measure

• Performance score of up to 80% points• Public Health Reporting Bonus Point• 100% points = Full Credit

CPIA N/A 15% • 10 Point “medium weight” activities & 20 Point “high-value” activities available

• 60 Points = Full Credit

Resource Use

Value-Modifier

10% • Similar Scoring to Quality Category

QualityAdvancing

Care Information

Clinical Practice



MIPS COMPOSITE SCORE SUMMARY

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TRANSFORMING CLINICAL PRACTICE IMPROVEMENT GRANT

• CMS $685 million awarded to equip >140,000 clinicians with tools needed to:

• Improve Care Quality• Increase Patients’ access to information• Assist in FFS>FFV Transformation• Population Health IT Infrastructure

• Caravan Health• Also known as “National Rural Accountable Care

Consortium”• Active in 43 states• Uses “Lightbeam” Population health Solution

• Compass PTN• Iowa Health Collaborative-Partnered with GHA • Active in 6 states• Uses “Telligen” Population Health Solution

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TRANSFORMING CLINICAL PRACTICE IMPROVEMENT GRANTPatient’s chief

complaints determines

care

Systemically assess all

patient health needs

Care is determined by

today’s problem

Care is determined by proactive care

plan

Traditional

Approach

Transformed

Practice

Care varies by scheduled time

Care is standardized according to

evidence-based guidelines

Patients are responsible for

coordinating their own care

A TEAM of professionals

coordinate patient care

What?

How?

When?

Who?

Via Population Health

Infrastructure

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QUESTIONS?