Considerations for Choosing MIPS Quality Measures - July 2017

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Considerations for Choosing MIPS Quality Measures - July 2017
Considerations for Choosing
  MIPS Quality Measures
            July 2017
Considerations for Choosing MIPS Quality Measures - July 2017
Overview of Contents
•   First know yourself
•   Finding measures
•   Understanding scoring
•   Special Considerations – about registries
•   Special Considerations – ESRD patients
•   Understanding the data that feeds measures – numerators, denominators,
    and excluders – OH MY!
•   Data capture in the typical workflow
•   Data quality and integrity
•   Notes and considerations on reporting
•   2018 proposed CMS updates
                               RPA Guide to QPP Participation                2
Considerations for Choosing MIPS Quality Measures - July 2017
First Know Yourself
Quality measurement is dependent on making sure you are choosing
measures that:
  • Reflect the most typical care you or your practice provide
  • Have reasonable distributions of performance (decile range benchmarks) so
    you can achieve high scores, even when you don’t have 100% performance
  • Require data that your electronic health record system can easily and
    discretely record

                               RPA Guide to QPP Participation                   3
Identifying and Choosing Measures
• Library of Measures at qpp.cms.gov
• 271 measures currently approved
• Must know the requirements for
  complete data and choose the
  method of how you or your group
  want to submit data
• Important to remember that
  measures are benchmarked and
  earning a score is dependent on
  deciles of performance and the
  submission method.
• Decile of performance equals point
  score; e.g. 9th decile = 9 points
                                                                                                                                                                                     4
      All tables adapted from http://healthcareblog.pyapc.com/2017/01/articles/pay‐for‐performance/optimizing‐your‐mips‐score‐quality‐measure‐benchmarks‐and‐reporting‐mechanisms/
Scores for MACRA/QPP – MIPS Quality Category
• Quality portion of MIPS composite score = 60 (out of 100) points for 2017
• Earning the 60 points is based on how well you (or your group) performs on
  the 6 chosen quality measures, where each measure is worth a maximum
  of 10 points.
• Groups of >16 clinicians will also be held accountable for a 7th measure –
  the AHRQ all cause hospital readmission measure. No reporting is required
  – data is aggregated and reported for you by CMS from claims data.
• There are bonus points achievable for choosing certain measures or using
  certified EHR technology (CEHRT).
• The 60 points of the MIPS composite score is the % of points out of 60 (or
  70 for groups >16) earned.
                               RPA Guide to QPP Participation           5
MIPS – Quality Measure Score Card Example
                                                              Bonus
       Measure
                         Measure
                          Type
                                         # of
                                        Cases
                                                Performance Points For
                                                   Points      High
                                                                         Bonus
                                                                       Points for Totals     • Group >16 clinicians, therefore 70
                                                             Priority
                                                                       CEHRT use
                                                                                               maximum possible points
                                                                                             • Did not meet the minimum # of reported
                         Outcome
                                                                 0
      Measure 1         Measure using    20         4.1                    1        5.1
                           CEHRT                             (required)
                                                                                               cases for measure #6
                        Process using
      Measure 2                          21         9.3        N/A         1        10.3
                           CEHRT
                                                                                             • Earned bonus points for reporting via EHR
      Measure 3
                        Process using
                           CEHRT         22         10         N/A         1         11        and choosing high priority measures
                                                                                               (#1,2,3, and 5)
      Measure 4            Process       50         10         N/A        N/A        10

                                                                                             • 53.9/70 = 77%
      Measure 5         High Priority    43         8.5          1        N/A       9.5
                                                                                               Quality Category Score
                        Process below
      Measure 6         case minimum     10          3         N/A        N/A        3
                                                                                             • 77% of 60 possible MCS =
   All‐Cause Hospital
     Readmissions
                           Claims       205          5         N/A        N/A        5         46.2 MIPS Composite Score Points
      Total Points      All Measures    N/A        49.9          1         3        53.9
From MACRA final rule TABLE 19: Quality Performance Category Example with High Priority and CEHRT Bonus Points                                                        6
https://www.federalregister.gov/documents/2016/11/04/2016-25240/medicare-program-merit-based-incentive-payment-system-and-alternative-payment-model-incentive-under
Notes on Scoring of Measures
• Score is based on the performance
  decile achieved according to
  published, benchmarked distribution.
• CMS publishes benchmarks for all
  measures on QPP.CMS.GOV
• Many measures are topped‐out,
  meaning there are very small
  performance differences separating
  the deciles.
• The same measure often has different
  benchmarks, depending on method of
  submission
• For 2017‐2018 EHR submission has
  the lowest percentage of topped out
  measures
                                                                                                                                                                                     7
      All tables adapted from http://healthcareblog.pyapc.com/2017/01/articles/pay‐for‐performance/optimizing‐your‐mips‐score‐quality‐measure‐benchmarks‐and‐reporting‐mechanisms/
Notes on Registries
• Qualified Registries (QRs) are approved vendors that aggregate and report
  quality data on behalf of subscribing clinicians and practices. MIPSwizard is
  an example.
• QCDRs (Qualified Clinical Data Registry) are databases that allow the
  collection and submission of the data needed to report on quality measures.
• QCDRs differ from Qualified Registries (QRs) in that QCDRs will offer both
  standard quality measures as well as custom, CMS‐approved quality
  measures that are not available in standard MIPS library of measures
  published by CMS. These custom measures may be specific to a disease or
  specialty of medicine. RPA’s Kidney Quality Improvement Registry (a QCDR)
  is an example.
• Both QRs and QCDRs typically charge subscription fees and may offer
  various visualization and other tools, beyond simple data aggregation and
  reporting                      RPA Guide to QPP Participation             8
Notes about ESRD patients
There is a lot of confusion about the ”requirements” for reporting across MIPS categories on ESRD patients.
• At a minimum (and depending on how a clinician or group reports data), CMS
  requires reporting on 50% of Part B patients who fall in the denominator of a
  chosen measure.
• When choosing measures, the types of encounters (based on CPT code)
  and/or disease state based on (ICD‐10) will determine which patients count in
  the denominator.
• There are very few measures that include the dialysis CPT codes (909XX) or
  N18.6 in the denominator.
• However, if a chosen measure does include ESRD services or patients, how to
  capture other needed data for the measure on enough patients will have to
  be considered given that EHR system use and robust data capture are not as
  easy in the dialysis setting. RPA Guide to QPP Participation             9
Understanding the data that feeds measures –
numerators, denominators, excluders, OH MY!

• For each chosen measure, it is important to ensure that for each data
  element required the following is known:
    • Where it is captured in the practice workflow?
    • Who is responsible for capturing it?
    • Which field‐specific data must be entered in the EHR?
    • What the acceptable range of responses are for each specific data
      element needed?

                             RPA Guide to QPP Participation           10
Example – Smoking Cessation – CMS #226
  Preventative Care and Screening: Tobacco Use
  Measure: Percentage of patients aged 18 years and older who were screened for tobacco use one or more
  times within 24 months AND who received cessation counseling intervention if identified as a tobacco user
           Denominator Inclusion                                  Numerator Inclusion                      Numerator Exclusion
                                                                                                    • NOT Screened for tobacco use
                                                                                                    and
Age > 18 on or after time of visit                         • reports no tobacco use
                                                                                                    • circumstances document (terminal
                                                                                                    illness, etc.)
                           and                             or                                                       or

A patient encounter resulting in a                                                                  No Screening and/or no intervention
CPT list defined by CMS*                                   • Reports current tobacco use
                                                                                                    for other documented reason

                                                           and                                                      or
*90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004,
92012, 92014, 96150, 96151, 96152, 97003, 97004, 99201,                                           No Screening and/or no intervention
99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215,    • received counseling (3 min or less),
                                                                                                  without documentation(measure
99406, 99407, G0438, G0439
                                                           pharmacotherapy, or both
                                                                                                  not met)                        11
                                                                   RPA Guide to QPP Participation
Report CPT 4004F

Measure
#226
Data                                                   Report CPT 1036F

Workflow
and CPTs                                               Report CPT 4004F‐1P
to be
reported
                                                       Report CPT 4004F‐8P

                                                                               12
           From https://pqrs.cms.gov/dataset/2016‐PQRS‐Measure‐226‐11‐17‐2015/s8gr‐6b6i/data
Matching Data Requirements to Workflow:
     Measure #226 Example
                                       How and Where is this data typically
                Required Data                                                       Who Captures the data?
                                                 captured?

Age≥ 18 @ time of visit                Typically calculated from DOB in EHR             Front office staff

                                       Chosen by provider @ time of
Visit CPT code                                                                      Provider (possibly coder)
                                       encounter completion/bill generation

                                       Automatically calculated based on
Date of visit                                                                           Auto generated
                                       date of service
                                       Typically a checkbox or part of social
Reports current tobacco use?                                                    Provider/Medical Assistant/Nurse
                                       history – varies on EHR
If tobacco user, was counseling        May be a CPT code, may be a separate
                                                                                            Provider
provided?                              checkbox – varies by EHR
                                       May be a checkbox, may be based on
If tobacco user, was pharmacotherapy
                                       specific Rx given during or after the                Provider
prescribed?
                                       visit completion – varies by EHR                                         13
Considerations on Data Capture
• What practice‐level incentives are in place to ensure staff and clinicians are
  capturing the right data, in the right place, and at the right time?
• What and how often are reports reviewing the quality and completeness of
  the data captured being run? Who reviews these reports? How is feedback
  offered to correct or praise people in the practice?
• What mechanisms, policies, and/or procedures are in place to amend the
  medical record if problems of missing or inaccurate data are discovered?
• For your EHR and other data tools, what is the time lag between when data
  is recorded/entered in the EHR to when scorecards or quality measure
  reports are updated for review?

                                 RPA Guide to QPP Participation             14
Considerations on Reporting Data to CMS…
Before allowing your registry vendor (QR, QCDR, or your EHR acting in the role of QR)
to submit data, consider the following:

• Have you sent test versions of your data to CMS? (will be available in some software in late
 2017)
• Have you confirmed what measures will be reported to CMS?
• Have you reviewed the data to be submitted for each clinician and checked it against
  internal reports?
• Will you have confirmation of transmission to CMS AND a copy of the exact data
  file(s) sent?
• Are you aware of when and how CMS will report their calculated MIPS score for
  your practice and/or clinicians?
• Are you aware of the deadlines and steps CMS offers to appeal/amend scoring on
  submitted quality (and other) data?

                                       RPA Guide to QPP Participation                     15
Possible Changes for 2018:
    Updates From the proposed rule released in June 2017
                     (see https://qpp.cms.gov/about/resource‐library)

• The quality category of MIPS will remain worth 60/100 points of the MIPS
  composite score for 2018.
• CMS has now proposed a nephrology specific quality measure bundle (See
  appendix table B.21 in the proposed rule and the next slide)
• CMS has proposed a bonus of up to 10 points for clinicians or groups that show
  significant year to year improvement between 2018 and 2019 reporting years.
• CMS proposes to accept data from more than one submission method for a single
  category. This may ease some burden of reporting quality on ESRD patients when
  data is gathered in multiple EHRs (office and dialysis unit‐based).
• CMS has proposed 1 possible change to scoring – measures with incomplete data
  may be scored at 1 point as opposed to 3 points (except for small and rural
  practices).
• CMS has proposed to sunset topped‐out measures over 4 year period starting in
  2018.                             RPA Guide to QPP Participation             16
2018 Proposed Rule:
    Possible Nephrology‐
  Specific Quality Measure
           Bundle

           Table B.21 in the
            proposed rule

RPA Guide to QPP Participation
For additional resources, including a list of
MIPS measures relevant to nephrology, visit
www.renalmd.org/physiciandevelopment

                     RPA Guide to QPP Participation   18
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