Merit-Based Incentive Payment System: 2018 Performance Year

 
Merit-Based Incentive Payment System: 2018 Performance Year
Knowledge Brief
Merit-Based Incentive Payment System: 2018 Performance Year

         The Merit-based Incentive Payment System (MIPS) impacts the 2020 Medicare Part B payment
          for billed visits in calendar year 2018.
         MIPS is one aspect of the Centers for Medicare and Medicaid Services’ Quality Payment
          Program; it is intended to prepare clinicians for participation in Advanced Alternative Payment
          Models by shifting from a volume-based payment system to one that is based on value.
         Patient experience surveying improves scoring opportunities in the Quality and Clinical Practice
          Improvement Activities measure categories.

Overview
The 2015 Medicare Access and CHIP Reauthorization Act (MACRA) repealed the Sustainable Growth
Rate payment methodology for physician services. MACRA combined the Physician Quality Reporting
System (PQRS), Electronic Health Record Meaningful Use (EHR MU) criteria, and Value-Based Payment
Modifier (VBPM) program requirements into a payment incentive program called the Quality Payment
Program (QPP).

Eligible clinicians can meet QPP requirements by participating in either Advanced Alternative Payment
Models (APMs) or the Merit-based Incentive Payment System (MIPS).

The Centers for Medicare and Medicaid Services (CMS) encourages Advanced APM participation
because it anticipates this model will result in higher quality care by improving care coordination and
customization. Qualified Advanced APM participants—those with at least 25% of their Medicare Part B
services or at least 20% of their Medicare beneficiaries covered through an Advanced APM—will receive
annual incentive payments, in addition to payment for services furnished, equal to 5% of their aggregate
payment amounts for Medicare-covered professional services in the preceding year. Incentive payments
begin in the 2019 payment year and continue through 2024 after which a 0.75% rate increase will be
implemented annually.

Clinicians who are not qualified participants in Advanced APMs will have Medicare Part B reimbursement
rates determined under the MIPS program. The MIPS program provides financial incentives to eligible
clinicians (ECs) to increase engagement with patients, families, and caregivers; to improve care
coordination; and to advance improvements in population health. ECs participating in an APM not
qualified as an Advanced APM are subject to Medicare payment determinations based on MIPS scores
in addition to any APM-specific financial incentives.

The Advanced APM is the national vision for a physician practice care model. MIPS is intended to
prepare eligible clinicians for participation in APMs by improving the capacity to meet benchmarks for
quality, clinical practice improvement, meaningful use of Certified EHR Technology (CEHRT), and
resource use (cost).

To help ECs participate successfully in MIPS and allow time for processes to be developed, CMS
continues to offer program flexibility in 2018.

© 2017 Press Ganey Associates, Inc.                                                                          1
MIPS Eligible Clinicians
For the 2018 performance year, the MIPS program includes five clinician types (referred to as eligible
clinicians, or ECs). These clinician types are unchanged from the 2017 performance year. Additional
clinician types should anticipate required participation in the 2019 performance year (Table 1). All clinician
types can participate voluntarily; data submission will not impact reimbursement if submitted on a
voluntary basis.

                                Table 1. Eligible Clinician Participation Requirements

        Years 1 & 2 ECs
                                                     Year 3 ECs
          (2017 & 2018                                                                   Excluded ECs
                                              (2019 Performance Year)
       Performance Years)
      Advanced Practice Nurses               Physical Therapists                  New clinicians: First year
      Certified Registered Nurse             Occupational Therapists               enrolled in Medicare Part B
       Anesthetists                           Speech-Language                      Small practices: Medicare
      Clinical Nurse Specialists              Therapists                            charges of < $90,000 or <
                                                                                     200 Part B Medicare
      Physician Assistants                   Audiologists                          beneficiaries
      Physicians                             Certified Nurse Midwives             Advanced APM
                                              Clinical Social Workers               participants: Collect > 25%
      Includes non-patient-facing                                                    of Medicare payments or
                 ECs*                         Clinical Psychologists                see > 20% of Medicare
                                              Registered Dietitians                 patients through the
                                                                                     Advanced APM

  *Definition of non-patient-facing ECs: Individal ECs who bill 100 or fewer patient-facing encounters, and groups
  with more than 75% of the TIN participants billing 100 or fewer patient-facing encounters.

To support the “Patients Over Paperwork” Initiative—aimed at removing regulatory obstacles that get in
the way of providers spending time with patients—CMS is excluding additional small practices in 2018 by
increasing the low volume thresholds to less than or equal to $90,000 in Medicare Part B charges, or less
than or equal to 200 Medicare Part B patients.

Participating small practices (groups of 15 or fewer ECs who exceed the small volume threshold) will be
awarded five bonus points toward the final MIPS score. Additionally, small practices will continue to earn
three points in the Quality category even if minimum submission requirements are not met, and are
eligible for a significant hardship exemption relative to CEHRT adoption. If a significant hardship
exemption is granted, three points will be awarded in the Advancing Care Information category even if
minimum submission thresholds are not met in that category.

The MIPS program allows for individual EC participation, group participation, and virtual group
participation. The payment adjustment for ECs submitting MIPS data as individuals is based on the
individual EC’s performance. ECs submitting MIPS data as a group will receive a payment adjustment
based on the group’s performance.

A group is defined as two or more clinicians (with unique National Provider Identifiers) who bill under a
single Tax Identification Number (TIN). The opportunity to participate as a virtual group is new for the
2018 performance year. Individual ECs and groups of ten or fewer ECs, that bill under different TINs, can

© 2017 Press Ganey Associates, Inc.                                                                                  2
choose to participate collaboratively as a virtual group. This requires a formal, written agreement among
all virtual group participants. See the CMS Virtual Groups Toolkit.

Individual ECs:
         Submit individual EC data for each of the MIPS categories
         Payment adjustment is based on individual MIPS Score
         Report data through EHR, Registry, a Qualified Clinical Data Registry, or Medicare Part B claims.

Groups (including Virtual Groups):
         Submit group-level data for each of the MIPS categories
         Individual EC payment adjustments are based on the group’s performance
         Report data through EHR, Registry or a Qualified Clinical Data Registry
         Groups of 25 or more can report through CMS Web Interface

For the 2018 performance year, ECs must make an election to participate as an individual, a group, or a
virtual group by December 31, 2017. CMS will identify MIPS ECs; non-patient facing clinicians; and small,
rural, and Health Professional Shortage Area (HPSA) practices. ECs will no longer self-identify their
status. See the guides in the Resources section of this document for help with MIPS registration.

Patient-centered medical homes (or comparable specialty practices) receive full credit for the 2020 MIPS
payment year. CMS defines an EC or group as a certified patient-centered medical home if at least 50
percent of the practice sites within the TIN are recognized as such.

Financial Impact
The MIPS program rules will first be applied to 2019 Medicare Part B payments for services, activities,
and outcomes relative to the 2017 performance period. This is referred to as year one. The 2018
performance period—or year two—will affect 2020 Medicare Part B payments.

For the 2018 performance year, the financial impact is increased to a ±5% maximum payment adjustment
for the 2020 payment determination and increases to ±9% for the 2022 payment determination (Table 2).
There is an imperative for practices to understand the high-risk MIPS poses for undermining financial
viability if data submission requirements are not met.

                            Table 2. Maximum MIPS Financial Impact by Payment Year

                        Payment Year          2019        2020          2021         2022

                     Performance Year         2017        2018          2019         2020

                    Maximum Payment
                                              ±4%         ±5%           ±7%          ±9%
                       Adjustment

MIPS Performance Categories
There are four performance categories in the MIPS program paradigm; three categories require data
submission, and each is weighted differently toward the overall score: Quality, Clinical Practice
Improvement Activity, Advancing Care Information, and Cost (Figure 1). The category weights vary by
year and will continue to evolve through rulemaking.

© 2017 Press Ganey Associates, Inc.                                                                         3
Figure 1. MIPS Category Weights by Performance Year/Payment Year

                       2017 / 2019                 2018 / 2020                      2019 / 2021

          ●Quality ●Clinical Practice Improvement Activity ●Advancing Care Information ●Cost
A notable exception to the weights depicted in Figure 1: For the 2018 performance year, the Advancing
Care Information category is weighted zero for non-patient-facing ECs, and the 25% weight is reallocated
to the quality category.

The different categories provide different perspectives on care delivered in the medical practice setting.
Each is subject to its own rules for measure selection and data submission. Patient experience surveying
can be used as a measure of performance in two categories: Quality and Clinical Practice Improvement
Activity (CPIA).

The Quality Category measures health outcomes and adherence to evidence-based practice.
Participants earn up to 10 points for each measure submitted. There are three options to maximize
scoring in this category:

     1. Select six quality measures: ECs and groups must submit six quality measures selected from a
          pool of over 300 evidence-based measures. One of these measures must be an outcome
          measure. If there is no applicable outcome measure, one of the six quality measures must be a
          high-priority measure. The MIPS Consumer Assessment of Healthcare Providers and Systems
          (MIPS CAHPS) survey counts as a high-priority quality measure.
                  ECs and groups may opt to submit more than six quality measures in which case the
                   highest scoring six measures will be applied to the quality category score.
                  If fewer than six quality measures pertain to the patient population, submit all that apply.
     2. Select a specialty-specific measure set: ECs and groups have the option to submit a pre-defined
          measure set specific to their specialty. There are 34 specialty-specific measure sets for the 2018
          performance year pre-loaded with all the measures applicable to the specialty (see Appendix A).
          If the measure set has more than six measures, the EC or group may select six for submission,
          including one outcome measure if available. If no outcome measure is available in the set, submit
          a high-priority measure.
                  Participants may opt to submit more than six measures (the highest scoring six measures
                   will be applied to the MIPS quality category score).
                  If there are six or fewer measures in the set, submit them all.

© 2017 Press Ganey Associates, Inc.                                                                               4
3. Select the CMS web interface measure set: Participants submitting quality measures via the CMS
          web interface must submit all measures pre-loaded into the interface mechanism for the first 248
          ranked and assigned Medicare beneficiaries as provided by CMS.
                  If the sample provided is less than 248, submit all measures for all cases.

Quality measures with benchmarks that have been topped out for at least two consecutive years will earn
participants a maximum of seven points each and will be phased out over four years. Topped out policies
do not apply to CMS Web Interface measures. For the 2018 performance year, there are six topped out
quality measures:
     1. Perioperative Care: Selection of Prophylactic Antibiotic-First or Second Generation
          Cephalosporin (Quality Measure ID 21)
     2.   Melanoma: Overutilization of Imaging Studies in Melanoma (Quality Measure ID 224)
     3.   Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL
          Patients) (Quality Measure ID 23)
     4.   Image Confirmation of Successful Excision of Image-Localized Breast Lesion (Quality Measure
          ID 262)
     5.   Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for
          Computerized Tomography (CT) Imaging Description (Quality Measure ID 359)
     6.   Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy (Quality
          Measure ID 52)

The All-Cause Hospital Readmission (ACR) measure is calculated for groups with 16 or more ECs with at
least 200 cases billed in the performance year. This is a claims-based measure that does not require data
submission on the part of the group. The ACR measure does not count toward the six measure
requirement; it is calculated in addition to any quality measures submitted. The ACR rate will be applied
to the quality category score even if no quality measures are submitted.

MIPS participants can earn up to 10 bonus points in this category by submitting additional high-priority
and outcome measures. MIPS CAHPS (available to groups) is worth two bonus points, other high-priority
measures are worth one bonus point each, and every additional outcome measure submitted is worth two
bonus points each.

     MIPS CAHPS is a high-priority quality measure available to ECs reporting as a group. For the 2018
     performance year, interested groups must indicate intent to participate in MIPS CAHPS on the CMS
     MIPS program registration website by June 30, 2018.

     The MIPS CAHPS survey includes the CAHPS Clinician and Group survey with additional questions
     (Table 3). CMS has removed two summary survey modules beginning with the 2018 performance
     year: “Helping You Take Medication as Directed,” and “Between Visit Communication.” CMS requires
     collection through a CMS-certified vendor.

                                Table 3. 2018 MIPS CAHPS Summary Survey Modules

                                      MIPS CAHPS Summary Survey Modules

                         Getting Timely Care, Appointments, and Information

                         How Well Providers Communicate

© 2017 Press Ganey Associates, Inc.                                                                          5
Patient’s Rating of Provider
                         Access to Specialists

                         Health Promotion and Education

                         Shared Decision-Making

                         Health Status and Functional Status

                         Courteous and Helpful Office Staff

                         Care Coordination

                         Stewardship of Patient Resources

          Press Ganey is a certified MIPS CAHPS vendor. The survey is administered annually; MIPS
          CAHPS surveying must span between eight and seventeen weeks ending no later than February
          28 following the performance year. Press Ganey will distribute MIPS CAHPS surveys November
          2018 through February 2019 for the 2020 payment determination.

          CMS indicates it is considering requiring MIPS CAHPS in future performance years. Given the
          significance of the surveys in CMS quality initiatives, understanding your position in MIPS CAHPS
          and targeting improvements before mandatory MIPS CAHPS performance evaluations are
          introduced is a valuable strategy.

          Furthermore, CMS values high-priority measures and provides incentives for selection and
          submission of these measure types. MIPS CAHPS is a high-priority measure. As such,
          participation earns groups two bonus points in the quality category score and provides several
          opportunities for groups to meet CPIA measure requirements.

          Accountable Care Organizations (ACOs) in Advanced Alternative Payment Models are not
          subject to MIPS. ACOs in APMs not qualified as Advanced (MIPS APMs) are subject to MIPS.
          However, CMS has defined a special “APM Scoring Standard” for the MIPS APMs. The data
          required to participate in the APM counts as the MIPS Quality and CPIA data for these ECs.

The Clinical Practice Improvement Activities Category encourages improvement activities
associated with better-quality health outcomes. In 2018, MIPS participants select from a list of 112
activities in eight subcategories:
     1. Achieving Health Equity (6 activities – 2 new)
     2. Behavioral and Mental Health (9 activities – 1 new)
     3. Beneficiary Engagement (23 activities)
     4. Care Coordination (17 activities – 3 new)
     5. Emergency Response and Preparedness (2 activities)
     6. Expanded Practice Access (5 activities – 1 new)
     7. Patient Safety and Practice Assessment (30 activities – 9 new)
     8. Population Management (20 activities – 6 new, 1 removed)

For the 2018 performance year, CMS removed PM_8: Participation in Capability Maturity Model
Integration from the Population Management subcategory, added 24 new activities, and modified 27

© 2017 Press Ganey Associates, Inc.                                                                        6
existing activities. ECs should aim to earn 40 CPIA points by selecting any combination of activities—
each worth either 10 or 20 points—with the following exceptions:
         Small practices, providers designated as rural or HPSAs, and non-patient facing participants
          need only 20 points to maximize scoring in this category.
         APMs participating in MIPS—those who are not qualified participants in Advanced APMs—must
          earn only 30 CPIA points to maximize their score in this category.
         Patient-centered medical homes are awarded all 40 points; no data submission is required in this
          category.

Reaching 40 CPIA points maximizes the potential score in this category for the majority of MIPS
participants. ECs are not required to submit enough CPIA measures to reach 40 points, but the impact on
the overall MIPS score, and thereby on reimbursement, provides a significant incentive to do so.

If reporting as a group, the group may submit any CPIA as long as at least one member of the group
performed the activity for at least 90 consecutive days in 2018.

Collecting MIPS CAHPS data and providing action plans to target improvements in patient engagement
and communication can readily earn a participant the 40 points targeted for the CPIA category (Table 4).
MIPS CAHPS also counts as one Quality category measure, serves as a high-priority quality measure,
and earns two bonus points on the Quality category. Therefore, MIPS CAHPS participation helps groups
meet multiple program requirements and boosts scores.

                      Table 4. Using Patient Experience Data to Meet CPIA Requirements

         CPIA Category                                         Activity                              Weight
 Patient Safety and Practice          Participation in the Consumer Assessment of Healthcare         20 points
 Assessment                           Providers and Systems survey or other supplemental
                                      questionnaire items.
 Patient Safety and Practice          Adopt a formal model for quality improvement and               10 points
 Assessment                           create a culture in which all staff actively participates in
                                      improvement activities. This could include sharing
                                      quality of care, patient experience, and utilization data
                                      with staff, patients, and families to promote transparency
                                      and accelerate improvement.

 Patient Safety and Practice          Ensure full engagement of clinical and administrative          10 points
 Assessment                           leadership in practice improvement. This could include
                                      incorporating population health, quality, and patient
                                      experience metrics in regular reviews of practice
                                      performance.

 Patient Safety and Practice          Measure and improve quality at the practice and panel          10 points
 Assessment                           level that could include one or both of the following:
                                         Regularly review measures of quality, utilization,
                                          patient satisfaction, and other measures that may
                                          be useful at the practice level and at the level of the
                                          care team or MIPS eligible clinician or group
                                         Use relevant data sources to create benchmarks and
                                          goals for performance.

© 2017 Press Ganey Associates, Inc.                                                                              7
CPIA Category                                       Activity                           Weight
 Expanded Practice Access             Collection of patient experience and satisfaction data    10 points
                                      on access to care and development of an improvement
                                      plan, such as outlining steps for improving
                                      communications with patients to help understanding
                                      of urgent access needs.

 Beneficiary Engagement               Collection and follow-up on patient experience and        20 points
                                      satisfaction data on beneficiary engagement, including
                                      development of improvement plan.

 Beneficiary Engagement               Regularly assess the patient experience of care through   10 points
                                      surveys, advisory councils, and/or other mechanisms.

 Beneficiary Engagement               Use of QCDR patient experience data to inform and         10 points
                                      advance improvements in beneficiary engagement.

The included activities do not require Certified Electronic Health Record Technology (CEHRT) to
complete. However, ECs and groups who can attest to using CEHRT functionality to complete a selected
activity will earn 10 bonus points toward the Advancing Care Information category score. The activities list
has increased in year two and includes 30 activities that allow for the CEHRT bonus in the 2018
performance year.

The Advancing Care Information Category measures use of technology for interoperability and
information exchange. Participants can earn up to 100 points in this category. The category score is
determined in three parts: Base Score + Performance Score + Bonus Points.

The Base Score is worth 50 points. Participants will earn all 50 points or none. To earn the base points,
the Security Risk Analysis measure must be answered yes, and the remaining required measures must
have at least one in the numerator. Only participants who meet the base point criteria will be eligible to
earn performance points (see the Performance Score column in Tables 5 and 6).

In the 2018 performance year—to maintain flexibility for ECs unable to implement the 2015 edition
CEHRT—ECs will continue to have the option to report the Advancing Care Information Transition
Measure set from the 2017 performance year (Table 6), or—for ECs acquiring the necessary 2015 edition
CEHRT capabilities—the 2018 performance year Advancing Care Information Objectives and Measures
(Table 5) using 2014 Edition CEHRT, 2015 Edition CEHRT, or a combination of the two.

Measure selection in this category depends in part on the CEHRT edition in use. Some ECs and groups
may be using a combination of CEHRT editions and will have the opportunity to select from across either
measure set. ECs will earn a 10 point bonus for using only the 2015 CEHRT in the MIPS 2018
performance year.

© 2017 Press Ganey Associates, Inc.                                                                          8
Table 5. 2018 Performance Year Advancing Care Information Objectives and Measures

                                                  Required
                                                  for Base            Performance                 Reporting
      Objective                   Measure          Score                 Score                    Standard
 Protect Patient            Security Risk             Yes         0                        Yes/No
 Health                     Analysis
 Information

 Electronic                 e-Prescribing             Yes         0                        Numerator/Denominator
 Prescribing

 Health                     Send a Summary            Yes         Up to 10 points          Numerator/Denominator
 Information                of Care
 Exchange
                            Request/Accept            Yes         Up to 10 points          Numerator/Denominator
                            Summary of Care
                            Clinical             No               Up to 10 points          Numerator/Denominator
                            Information
                            Reconciliation

 Patient Electronic         Provide Patient           Yes         Up to 10 points          Numerator/Denominator
 Access                     Access

                            Patient-Specific     No               Up to 10 points          Numerator/Denominator
                            Education

 Coordination of            View/Download/or     No               Up to 10 points          Numerator/Denominator
 Care Through               Transmit
 Patient
 Engagement                 Secure Messaging     No               Up to 10 points          Numerator/Denominator

                            Patient Generated    No               Up to 10 points          Numerator/Denominator
                            Health Data†

 Public Health &            Immunization         No               Zero or 10 points*       Yes/No
 Clinical data              Registry
 Registry                   Reporting†
 Reporting
                            Syndromic            No               Zero or 10 points*       Yes/No
                            Surveillance
                            Reporting

                            Electronic Case      No               Zero or 10 points*       Yes/No
                            Reporting†

                            Public Health        No               Zero or 10 points*       Yes/No
                            Registry Reporting

                            Clinical Data        No               Zero or 10 points*       Yes/No
                            Registry
                            Reporting†
† Requires  2015 Edition.
* Participants earn 10 performance points for reporting to any single public health agency or clinical data registry. An
additional five bonus points are awarded for reporting to more than one.

© 2017 Press Ganey Associates, Inc.                                                                                        9
Table 6. Transition Advancing Care Information Objectives and Measures

                                                 Required
                                                 for Base       Performance           Reporting
      Objective                   Measure         Score            Score              Standard
 Protect Patient            Security Risk             Yes   0                   Yes/No
 Health                     Analysis
 Information

 Electronic                 e-Prescribing             Yes   0                   Numerator/Denominator
 Prescribing

 Health                     Health Information        Yes   Up to 10 points     Numerator/Denominator
 Information                Exchange
 Exchange
                            Clinical             No         Up to 10 points     Numerator/Denominator
                            Information
                            Reconciliation

 Medication                 Medication           No         Up to 10 points     Numerator/Denominator
 Reconciliation             Reconciliation

 Patient Electronic         Provide Patient           Yes   Up to 20 points     Numerator/Denominator
 Access                     Access

                            View/Download/or     No         Up to 10 points     Numerator/Denominator
                            Transmit

 Patient-Specific           Patient-Specific     No         Up to 10 points     Numerator/Denominator
 Education                  Education

 Secure                     Secure Messaging     No         Up to 10 points     Numerator/Denominator
 Messaging

 Public Health              Immunization         No         Zero or 10 points   Yes/No
 Reporting                  Registry Reporting

                            Syndromic            No         Zero or 10 points   Yes/No
                            Surveillance
                            Reporting

                            Specialized          No         Zero or 10 points   Yes/No
                            Registry Reporting

Not all ECs in a group need to contribute data to the selected measures in this category. Only one EC in
a group needs to be collecting data relative to each selected measure. However, groups should submit all
available data for each selected measure.

If none of the Advancing Care Information measures apply to a participating EC or group, or if an EC or
group can demonstrate significant hardship in implementing health information technology, CMS will
reweight the category to zero and assign the 25% weight to other performance categories to offset the
difference in the MIPS final score.

© 2017 Press Ganey Associates, Inc.                                                                       10
The Cost Category measures and compares costs to treat Medicare beneficiaries. For 2018, the MIPS
cost category includes the Medicare Spending per Beneficiary measure and the total per capita cost
measure. CMS is retiring the 10 episode-based measures from this category for the 2018 performance
year. New episode-based cost measures are under development for consideration for future years.

This category is claims based; no data submission is required. Note that the cost measures bear a 10%
weight toward the overall score for the 2018 performance year. This is an increase from a weight of zero
in program year one. It will increase to a 30% weight in the 2019 performance year.

Data Submission
There are a variety of data-submission methods that vary in availability depending on the data category.
The number of measures, minimum case requirements, claims type, collection timeframes, and deadlines
also vary depending upon the data category and submission method (Table 7).

CMS encourages participants to submit all measures in a category via one submission mechanism.
However, it is acceptable (and sometimes necessary) to select different submission mechanisms for
different categories.

                   Table 7. Data Submission Requirements for the 2018 Performance Year

                                                      Minimum
                           Data         No. of         No. of                       Data         Data
      Data              Submission     Required       Cases to        Claims     Collection   Submission
    Category            Mechanism      Measures        Submit          Type      Timeframe     Timeline

 Quality                QCDR         Up to six      60% of          All payer   Full CY      January 1 -
                        Qualified                   patients                    2018         March 31,
                         Registry                    meeting the                              2019
                                                     denominator
                        CEHRT
                                                     criteria

                       Part B         Up to six      60% of          Medicare    Full CY      2018 claims
                       Claims*                       patients        Part B      2018         processed
                                                     meeting the                              by Jan 29,
                                                     denominator                              2019
                                                     criteria
                       CMS Web        All measures   The first 248   Medicare    Full CY      An eight-
                       Interface**    prepopulated   cases listed    Part B      2018         week period
                                      in the CMS     If fewer than                            between
                                      Web            248 submit                               January 1
                                      Interface      all cases                                and March
                                                     provided                                 31, 2019

                       CMS            MIPS           Meet survey     Medicare    Full CY      Distributed
                       Certified      CAHPS          sample          Part B      2018         November
                       Vendor                        requirement                              2018 -
                                                                                              February
                                                                                              2019

© 2017 Press Ganey Associates, Inc.                                                                         11
Minimum
                           Data                 No. of               No. of                               Data               Data
      Data              Submission             Required             Cases to            Claims         Collection         Submission
    Category            Mechanism              Measures              Submit              Type          Timeframe           Timeline

                       Claims               All Cause             N/A                 Medicare         Full CY            Submit all
                                            Hospital                                  Part A &         2018               2018 claims
                                            Readmission                               B                                   by Jan 29,
                                            Measure                                                                       2019

 Cost                  N/A                  Two                   20 cases for        Medicare         Full CY            Submit all
 Management                                                       each                Part A &         2018               2018 claims
                                                                  measure             B                                   by Jan 29,
                                                                                                                          2019

 Advancing              Attestation        Four in the           A Yes               N/A              Any 90             January 1 -
 Care                   QCDR               Transition            answer, or                           consecutiv         March 31,
 Information            Qualified          measure set           one case in                          e days in          2019
                         Registry           Five in the           each                                 2018
                        CEHRT              2018                  measure                              Up to a full
                                            measure set           numerator                            CY of data
                        CMS Web                                                                       Full CY
                         Interface**                                                                   2018

 Clinical               Attestation        Up to four            One                 N/A              Any 90             January 1 -
 Practice               QCDR                                     affirmative                          consecutiv         March 31,
 Improvement                                                      attestation                          e days in          2019
                        Qualified
 Activity                                                         for each                             2018
                         Registry
                                                                  activity†                            Up to a full
                        CEHRT
                                                                                                       CY of data
                        CMS Web                                                                       Full CY
                         Interface**                                                                   2018
* Individual ECs only; ** Groups of 25 or more; † Plus an attestation that a third party is submitting on your behalf if this is this case.

Groups submitting data via the CMS Web Interface and groups opting to submit MIPS CAHPS data must
register for those options via the CMS Enterprise Portal by June 30, 2018, for the 2018 performance
period. Data completeness for virtual groups applies cumulatively across all TINs in a virtual group.

For the 2018 performance year, quality and cost categories require a full CY 2018 data. The CPIA and
Advancing Care Information categories maintain the minimum 90-consecutive day performance period.

Scoring
Each submitted measure is scored based on comparison to national benchmarks. The measures within
each category are then summed to a category score, and the category scores are given a weight toward
the overall MIPS score. The overall score is then compared to a national performance threshold (PT) that
is determined annually based on the average MIPS composite score nationally. Payment adjustments are
based on a sliding scale relative to the quartile of performance as compared to the PT (Figure 2). Final
scores at or below 3.75 will result in the full -5% downward payment.

© 2017 Press Ganey Associates, Inc.                                                                                                       12
Figure 2. MIPS 2019 Payment Year Adjustment Range

Each measure category uses a different scoring methodology.

                                                  Quality Score
In the Quality category, each submitted measure earns from three to 10 achievement points depending
on performance against national benchmarks.
Beginning with the 2018 performance year, for measures that have two years of data available, an
improvement score is calculated based on the rate of increase in the achievement score year to year1.
CMS allowances for the 2018 performance year:
         Any quality measure submitted via Part B Claims, CMS Web Interface, or CMS Certified Vendor
          that does not meet minimum case requirements will earn three points.
         Any quality measure submitted via EHR, QCDR, or qualified registry that does not meet minimum
          case requirements will earn one point.
         Any quality measure submitted by a small practice that does not meet minimum case
          requirements—regardless of submission mechanism—will earn three points.
The category score is calculated by first adding points earned for the six submitted measures, the ACR,
and bonus points, then dividing the sum by the number of measures submitted times ten, plus the number
of improvement points earned. The category score cannot exceed 100.

      [Achievement points earned on quality measures] + [ACR] + [Bonus points]
                                                                               + Improvement Points
                                        6 required measures x 10

  1
   This provides an incentive for eligible clinicians to focus on improvement by allowing for extra points
  when the same measures are submitted year after year and improvement is demonstrated.

© 2017 Press Ganey Associates, Inc.                                                                          13
Clinical Performance Improvement Activity Score

The CPIA category score first determines the points for each submitted activity (10 or 20). The total
number of points is divided by 40 (the maximum points for 2018) and multiplied by 100.

                                            Points earned from submitted activities x 100
                                                     40 maximum points

Exceptions for the 2018 performance year:
         Small practices, rural, HPSAs, and non-patient facing ECs calculate the score with a denominator
          of 20.
         APM participants (not qualified as Advanced APMs) calculate the score with a denominator of 30.
         Patient-centered medical homes are awarded all 40 points.

                                             Advancing Care Information Score

The Advancing Care Information category relies on receiving the 50 base points by successfully
submitting the required measures. Participants who do not meet the submission requirements for those
measures will be scored zero in this category. Those who do acquire the 50 base points will then be
assessed for performance and bonus points.

                      Base score (50) + Performance score (max 90) + Bonus score (max 15)

                                                         Cost Score

In the Cost category, each measure earns between one and 10 points based on the EC’s decile of
performance compared to the measure benchmarks. National deciles of performance are calculated
using data from the performance period. The category score is the average of the two included measures.

Beginning with the 2018 performance year, for measures that have two years of data available, an
improvement score is calculated based on the rate of increase in the achievement score year to year2.

                        Achievement points earned from submitted measures + Improvement Points
                                           Two measures

  2
   This provides an incentive for eligible clinicians to focus on improvement by allowing for extra points
  when the same measures are submitted year after year and improvement is demonstrated.

© 2017 Press Ganey Associates, Inc.                                                                          14
Earning Bonus Points
There are various ways for MIPS participants to earn bonus points toward the final MIPS score (Table 8).

                                Table 8. MIPS Bonus Points for the 2018 Performance Year

              Category                       Bonus Points                    Earning Bonus Points

 Final Score: Small Practice            5 Points                   EC or group defined as a small practice (in
 Bonus                                                             a group of 15 or fewer ECs) that submits
                                                                   data for at least one performance category.

 Final Score: Complex                   Up to 5 Points             Clinicians can earn up to 5 bonus points for
 Patients Bonus                                                    the treatment of complex patients (based on
                                                                   a combination of the Hierarchical Condition
                                                                   Categories (HCCs) and the number of
                                                                   dually eligible patients treated).

 Quality Category Score                 1 Point (Max 10)           For every high-priority or outcome measure
                                                                   submitted beyond basic requirements
                                                                   (including MIPS CAHPS).

                                        2 Points                   Groups that submit MIPS CAHPS.
 Advancing Care Information             10 Points                  Attest to using CEHRT functionality to
 Category Score                                                    complete an improvement activity (applied
                                                                   to 18 specified improvement activities only).

                                        5 Points                   For reporting to an additional public health
                                                                   or clinical data registry measure beyond
                                                                   those required for the Advancing Care
                                                                   Information performance score.

                                        10 Points                  Use only 2015 edition CEHRT in 2018.

                                                     MIPS Score

Although some category scores can exceed 100, MIPS category scores and the overall score are all
capped at 100. To calculate the final, overall MIPS score each category score is multiplied by its weight
and these weighted category scores are summed. The scoring for the 2018 performance year is as
follows:

                        ([Quality category score x 50%] + [CPIA category score x 15%]
              + [Advancing Care Information category score x 25%] + [Cost category score x 10%]
                                             + Bonus Points) x 100

Multiply either each category score or the overall score by 100 to convert from a percentage to a point
value. See Appendix B for a scoring example.

© 2017 Press Ganey Associates, Inc.                                                                                15
For performance year 2018, the PT is set at 15 points. This is the breakeven point. Scoring below this
threshold will result in a downward payment adjustment, scoring at or above this threshold in the MIPS
2018 performance year will prevent a downward adjustment for the 2020 payment determination.

Submitting the full set of requirements—six quality measures, five Advancing Care Information measures,
and enough CPIA measures to reach the 40-point threshold—will better position participants for a positive
adjustment. Those attaining a final score of 70 or better will receive an additional MIPS payment
adjustment factor and may share in the $500 million available for exceptional performers (Table 9).

            Table 9. 2020 Payment Adjustment Based on 2018 Performance Year MIPS Score

       Final Score                                          Payment Adjustment
                                  Positive adjustment
        > 70 Points
                                  Eligible for exceptional performance bonus—minimum of additional 0.5%

                                  Positive adjustment up to +5%
      16 – 69 Points
                                  Not eligible for exceptional performance bonus
          15 Points               Neutral, no payment adjustment

     3.76 – 14 Points             Negative payment adjustment up to -5%

      0 - 3.75 Points             -5% Negative Payment Adjustment

Failing to reach the 15 point performance threshold for the 2018 performance year will result in a
reduction in Medicare Part B reimbursement for the 2020 payment year. Participants should anticipate
more stringent participation requirements and higher financial risk in future years.

MIPS data will be publicly reported on Physician Compare beginning with the 2017 performance year
data. The date of publication is to be determined and may vary by measure type.

Conclusion
A great deal of flexibility was maintained for EC participation in the MIPS 2018 program year. However,
the financial stakes are higher, and CMS has built-in significant incentives for clinicians to develop
integrated care models—including patient engagement—and to advance health information technology
capabilities.

Submitting additional measures and taking advantage of bonus points will help participants achieve an
upward payment adjustment. Meeting all requirements greatly improves the odds of receiving an upward
payment adjustment, and exceeding requirements increases the odds of receiving additional high-
performer incentive funds.

The MIPS program intends to advance national goals for improving the quality of health care by
increasing patient engagement and patient-centeredness, and supporting an outcome-focused, resource-
efficient health system.

To intensify efforts to improve the patient experience, CMS has designed strategic advantages to
participating in MIPS CAHPS. Groups participating in MIPS CAHPS meet multiple measure requirements
across Quality and Clinical Practice Improvement Activity categories and earn two bonus points toward
the Quality category score, which has a direct impact on the 2020 payment determination.

© 2017 Press Ganey Associates, Inc.                                                                       16
Resources

CMS Quality Payment Program
CMS Quality Payment Program Resource Library
CMS Quality Payment Program Educational Webinars

MIPS Participation Requirements by National Provider Identifier

Guide for Obtaining a New EIDM Account with a ‘Physician Quality and Value Programs’ Role

Guide for Obtaining a ‘Physician Quality and Value Programs’ Role for an Existing EIDM User

© 2017 Press Ganey Associates, Inc.                                                           17
Appendix A: Specialty Measure Sets

                          MIPS Specialty Measure Sets for the 2018 Performance Year
       1. Allergy / Immunology
       2. Anesthesiology
       3. Cardiology
       4. Gastroenterology
       5. Dentistry
       6. Dermatology
       7. Diagnostic Radiology
       8. Electrophysiology Cardiac Specialist
       9. Emergency Medicine
       10. Family Medicine
       11. General Surgery
       12. Hospitalist
       13. Infectious Disease
       14. Internal Medicine
       15. Interventional Radiology
       16. Mental / Behavioral Health
       17. Nephrology
       18. Neurology
       19. Neurosurgery
       20. Obstetrics / Gynecology
       21. Ophthalmology
       22. Orthopedic Surgery
       23. Otolaryngology
       24. Pathology
       25. Pediatrics
       26. Physical Medicine
       27. Plastic Surgery
       28. Podiatry
       29. Preventive Medicine
       30. Radiation Oncology
       31. Rheumatology
       32. Thoracic Surgery
       33. Urology
       34. Vascular Surgery

© 2017 Press Ganey Associates, Inc.                                                   18
Appendix B: Scoring Example for a Medium Size Practice

                 Performance Category        Performance Score Category Weight   Earned Points
                          [A]                       [B]              [C]          [B]*[C]*100

                Quality                            75%              50%              37.5

                Cost                               50%              10%               5

                Improvement Activities             100%             15%               15

                Advancing Care Information         100%             25%               25

                Subtotal                                                             82.5
                (Before Bonuses)

                Complex Patient Bonus                                                 3

                Small Practice Bonus                                                  0

                Final Score                                                          85.5
                (not to exceed 100)

© 2017 Press Ganey Associates, Inc.                                                              19
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