MACRA/MIPS Quality Measurement for Plastic Surgeons 2018

MACRA/MIPS Quality Measurement for Plastic
            Surgeons 2018

Quality Payment Program

MIPS Replaced Three Programs

CMS Meaningful Measure Initiative

MACRA/MIPS Rule 2018: Impact on Quality
 Eligibility criteria dramatically increase:
   Must bill > $90,000 in Part B charges AND
   Must see > 200 Part B beneficiaries
   Exempt if either of the above do not apply

 Important to evaluate your eligibility status and continue to be aware of
   applicable MIPS and non-MIPS ASPS quality measures

 5% Penalties in 2020 based on 2018 reporting (4% in 2019 for 2017)

MIPS Eligible Clinicians

Exempt Clinicians

Exemption Categories

Special Status Clinicians

Reporting Periods

Timeline

Reporting Options

Quality Measure Scoring
 Basics:                          3-point floor with
   Need to select 6 measures        benchmarks or without
    including one Outcome or         benchmarks
    High-Priority measure
   270+ measures available        Need 20 cases minimum
    and Plastic Surgery Measure    Bonus for high-priority
    Set
                                     measures up to 10% of
   Can report measures from         denominator in performance
    the CMS Specialty Specific
                                     category
    Measure Set
                                   Bonus up to 10% for end to
                                     end electronic reporting of
                                     denominator in performance
                                     category

Plastic Surgery MIPS Specialty Set
 Perioperative Care: Selection of     Preventive Care and Screening:
   Prophylactic Antibiotic-First OR      Tobacco Use Screening and
   Second Generation                     Cessation Intervention
   Cephalosporin
                                       Unplanned Reoperation within
 Perioperative Care: VTE                the 30-day Postoperative Period
 Documentation of Current             Unplanned Hospital
   Medications in Medical Record         Readmission within 30 Days of
                                         Principal Procedure
 Preventive Care and Screening:
   Blood Pressure and Follow-up        Surgical Site Infection
   Documented
 Patient-Centered Surgical Risk
   Assessment and
   Communication

Improvement Activities Scoring
 Basics:                            Number of Activities:
     15% of Final Score in 2018       Need 40 points
     112 Activities available         Burden Reduction Aim:
     High Weighted=20 points            Small and rural practices can
                                         report 2 activities to achieve
     Medium Weighted=10 points
                                         the highest score
     Simple Attestation Required
                                       CMS Audit Potential: need to
                                         keep documentation for 90
                                         days

Cost Measure Scoring

Advancing Care Information 2018 Scoring
 Basics                              Exceptions &
   25% of Final Score in 2018         Reallocations to 25% to the
   Base Performance + Bonus           Quality category for the
     Scores                            following:
   Promotes patient                    Automatic for hospital based
     engagement and use of                MIPS eligible and
     certified electronic                 Ambulatory Surgical Center
     technology                           MIPS eligible
   Two measure sets based on           Application for new hardship
     the edition of the electronic        exemption for small practices
     health record                        (15 or fewer physicians)-
                                          deadline December 31

Physician Compare

Qualified Clinical Data Registry (QCDR)
 CMS approved entity that collects clinical data
  on behalf of eligible clinicians
 Includes MIPS and non-MIPS Measures
 Reporting is done over one calendar year
 CMS reserves the right to audit quality
  measures so documentation should be
  maintained by clinician

ASPS Qualified Clinical Data Registry

QCDR Implementation
 Established in 2016 with only 6 members

 In 2017 had only 15 that entered more than minimal claim data

 Limited number of members provide reconstructive care for
   Medicare patients

 Members complained about reporting burden using paper claims
   with limited use of electronic medical records

 Private payers are expected to require quality reporting which has
   begun in New York

2018 ASPS QCDR
 Expanded platform to allow group and electronic
  medical record reporting to reduce reporting burden

 Continue to rapidly produce plastic surgery specific
  non-MIPS measures using national development
  systematic processes

 Currently working on Rhinoplasty measure set
 Register now and begin entering cases!

CMS Approved 2018 QCDR Measure Portfolio
   Breast Reconstruction: Return to the              Unplanned Hospital Admission after
    Operating Room                                     Panniculectomy

   Breast Reconstruction: Flap Loss                  Wound Disruption Rate after Primary
                                                       Panniculectomy in Patients with BMI ≥ 35
   Offloading for Diabetic Foot Ulcer (licensed
    from the US Wound Registry)                       Wound Disruption Rate after Primary
                                                       Panniculectomy in Patients with BMI < 35
   Rate of Blood Transfusion for Patients
    Undergoing Autologous Breast                      Seroma Rate after Panniculectomy
    Reconstruction
                                                      Seroma Rate after Abdominoplasty (QI)
   Coordination of Care for Patients
    Undergoing Breast Reconstruction                  VTE Screening for panniculectomy and
                                                       abdominoplasty (QI)
   Length of Stay Following Autologous Breast
    Reconstruction                                    Wound disruption rate after abdominoplasty
                                                       (QI)
   Patient Satisfaction with Information
    Provided during Breast Reconstruction

   Operative Time for Autologous Breast
    Reconstruction

Where Do I Start?
 Check your MIPS eligibility at
  qpp.cms.gov/participation-lookup

 If you are eligible, consider registering for the ASPS
  QCDR. Find additional information on our QCDR web
  page https://www.plasticsurgery.org/qcdr

 If you have questions, please contact our Quality mail
  box at quality@plasticsurgery.org

CMS Resources
 Quality Payment Program: QPP@cms.hhs.gov
  or 1-866-288-8292
 QPP Listserv:
  https://public.govdelivery.com/accounts/USCM
  S/subscriber/new?preferences=true

Questions?
Carol Sieck, PhD, RN-Director
csieck@plasticsurgery.org

Caryn Davidson, MA- Senior
Quality Analyst QCDR Lead
cdavidson@plasticsurgery.org