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Hello again! As promised, I’m back with more simply explained goodies about MIPS scoring for the 2017 performance year. In Part 1 of this series, we discussed the Basics of MIPS Scoring. That post is chock full of great information (if I do say so myself!) so definitely check it out. In today’s post, Part 2, we’ll cover scoring the Quality category. Then, in Part 3, we’ll discuss scoring for the Improvement Activities category. And finally, Part 4 will cover Advancing Care Information scoring, tying it altogether with an overview of the MIPS payment adjustment calculation. But, first, Quality!

The Basics of Scoring the Quality Category

For most of our MIPS Registry participants, the Quality category feels the most comfortable. Many of the principles we came to learn and love in PQRS hold true in MIPS Quality, so it’s less of a puzzle to figure out. But, there are some important differences, and scoring is one of them. Keep in mind that Quality is worth the largest portion - at least 60% - of the overall MIPS Final Score (a calculation I’ll discuss in Part 4), so if you’re aiming for a positive payment adjustment, this category is an important one to pay attention to.  

For the quality category, each reported measure will receive between 3 and 10 points. In order to be considered to receive more than 3 points, a reported measure must:

1) Comprise of at least 20 reported qualifying events;
2) Have a benchmark; and
3) Meet the data completeness standard.*

*For registry, QCDR, and EHR reporting, data completeness means that measures must be reported on at least 50% of the qualifying events for that measure, based on your entire patient population (not just Medicare Part B FFS patients), and must include at least one Medicare Part B FFS patient.

If any of the above features are missing, the measure will receive 3 points. But, if all the above features are established, the measure can receive up to 10 points. To determine whether more points will be awarded, CMS compares your measure’s performance data to a national benchmark. The benchmarks provide a comparison point to determine if your performance was higher than the national average, thus meriting more points.

You’re probably now wondering: where does the national benchmark data come from? Well, for the MIPS 2017 performance year, the benchmarks are based on 2015 PQRS performance data. Each benchmark is broken down into performance deciles, with the worst performance in deciles 3 and below and the best performance in decile 10. Benchmarks also vary from submission mechanism to submission mechanism. So, there is a different benchmark for EHRs, Registries, QCDRs, etc. You can check out the benchmark data that will be used for the 2017 performance year by going to the QPP website’s resource library and downloading the zip file called “2017 Quality Benchmarks.”

So, this is the basic methodology used to score the Quality category. Ultimately, your score depends on the benchmark, but as a rule of thumb, you want to have the highest possible quality performance to maximize points per measure. Also, note that, unlike PQRS where you received an automatic ding if didn’t fully report, with MIPS Quality, if you report less than 6 measures, and you’ll be scored on whatever is submitted, and receive a “0” score for measures that you could have submitted but didn’t. So, your score won’t be high in this scenario, but it’s not an automatic negative. On the other side of the spectrum, if you choose to report more than 6 measures, your outcomes or high priority measure will be scored, and then the measures with the highest points earned will be used in your score. But, note that all measure results submitted will become public information, so consider your quality reporting strategy carefully before submission.

Bonus Points Awarded in the Quality Category

Before we move on from Quality scoring, there is one more thing you should know. That is, you can receive bonus points in the quality category for two separate reasons. The first is by reporting additional high priority measures, and the second is by reporting measures via end to end electronic reporting.

Bonus Points Earned by Reporting Additional High Priority Measures

The first way to earn bonus points in the Quality category is to report additional high priority measures. But, there are three nuances to earning these bonus points that you should keep in mind:

1) The total amount of bonus points available is capped at 10% of the total points available to the reporter in the quality category. So, this isn’t a huge bonus, but it’s still a bonus!
2) To receive bonus points, you must submit at least the one required, fully reported, scored outcomes or high priority measure. So, make sure at least your first outcomes or high priority measures has 20 cases reported and 50% of all encounters, plus at least 1 Medicare Part B FFS patient.
3) Bonus measures themselves must have at least 20 cases reported and 50% of all encounters, plus at least 1 Medicare Part B FFS patient.

Assuming the above is considered and satisfied, bonus points are awarded as follows:

- Each additional outcome or patient experience measure = 2 bonus points.
- Each additional high priority measure = 1 bonus point.

Note that if you don’t report six measures, you can still earn bonus points, but only if you’re doing so because of lacking availability of applicable measures. Otherwise, you can earn bonus points on as many high priority measures as you report - both including the initial six, and including any additional measures you report. So, be sure your measure selection strategy includes as many outcomes and high priority measures as possible!

Bonus Points Earned by Reporting Via End to End Reporting

The second way to earn bonus points in the Quality category is to report your measures via end to end electronic reporting. But, again, earning these bonus points has some nuances to keep in mind:

1) The amount of bonus points available is capped at 10% of the total points available to the reporter in the quality category. So, this isn’t a huge bonus either. But, note that each bonus point category is a separate cap, so you can max out both separately.
2) Bonus points can be earned only if reporting via qualified registries, QCDRs, EHRs, or the CMS Web Interface, and when end to end electronic reporting is utilized. Claims reporters won’t qualify for these bonus points.

Keeping these considerations in mind, each measure reported via end to end electronic reporting will receive 1 bonus point.

Once all of that is determined, both types of bonus points are added to the score from the initial measures, and then divided by the total points available to that reporter in the quality category. This number is then multiplied by 60, which is the weight of the quality category in the final score. This is your final score for the Quality category.

 

Image: 2017 MIPS Quality Performance Category Fact Sheet


Yahoo! That’s Everything for Quality!

We made it through Quality scoring! Noice! One last note before we go -  all the information above is most relevant to 2017 performance year registry reporting, and there are some quirks depending on which type of submission mechanism you choose. pMD is a qualified registry, so we focused on that aspect of MIPS Quality scoring. If you have any questions or would like to learn more about our MIPS registry, give us a call! And, of course, to find out more about pMD's suite of products, which includes charge capture, secure messaging, and care coordination software and services, please contact pMD.

References:

Each reported quality measure will receive between 3 and 10 points: “[W]e will provide points for all submitted measures, but only a subset of measures receives points based on performance against a benchmark.” See https://www.federalregister.gov/d/2016-25240/p-3502; see also Table 17 in the Final Rule at https://www.federalregister.gov/d/2016-25240/p-3502 (illustrating that there are two categories for submitted quality measures one category that recieves 3 points and one category that receives between 3 and 10 points).

To receive more than 3 points, the reported quality measure must have a benchmark, have 20 cases, and meet the data completeness standard: See Table 17 in the Final Rule at https://www.federalregister.gov/d/2016-25240/p-3502.

When reporting through QCDRs, qualified registries, and EHRs, data completeness means reporting on 50% of all-payer data for that measure, and including at least one Medicare patient: Data completeness will include “all-payer data for the QCDR, qualified registry, and EHR submission mechanisms... In addition, those clinicians who utilize a QCDR, qualified registry, or EHR submission must contain a minimum of one quality measure for at least one Medicare patient.” See https://www.federalregister.gov/d/2016-25240/p-1492.

If any of the reported quality measures are missing the minimum requirements, they will receive 3 points: See Table 17 in the Final Rule at https://www.federalregister.gov/d/2016-25240/p-3502; see also 81 FR 77286, available at https://www.federalregister.gov/d/2016-25240/p-3476.

Comparing reported quality data against the national benchmark determines if a measure will receive more than 3 points: “When a clinician submits measures for the MIPS Quality Performance Category, each measure is assessed against its benchmarks to determine how many points the measure earns.” See Quality Measure Benchmarks Overview pdf, pg. 1, available for download from https://qpp.cms.gov/about/resource-library, in a zip titled “2017 Quality Benchmarks.”; see also 81 FR 77286, available at https://www.federalregister.gov/d/2016-25240/p-3476.  

National benchmark data used for the MIPS 2017 performance year is taken from 2015 PQRS performance data: “These historic benchmarks are based on actual performance data submitted to PQRS in 2015, except for CAHPS.” See Quality Measure Benchmarks Overview pdf, pg. 1, available for download from https://qpp.cms.gov/about/resource-library, in a zip titled “2017 Quality Benchmarks.”

Each benchmark is broken into deciles: “Each benchmark is presented in terms of deciles.” See Quality Measure Benchmarks Overview pdf, pg. 1, available for download from https://qpp.cms.gov/about/resource-library, in a zip titled “2017 Quality Benchmarks.”; see also 81 FR 77286, available at https://www.federalregister.gov/d/2016-25240/p-3476.

There is a different benchmark for each submission mechanism: “Benchmarks are specific to the type of submission mechanism: EHRs, QCDRs/Registries, CAHPS and claims.” See Quality Measure Benchmarks Overview pdf, pg. 1, available for download from https://qpp.cms.gov/about/resource-library, in a zip titled “2017 Quality Benchmarks.”

To maximize your MIPS score, you should fully report at least 6 measures: “[F]or any MIPS eligible clinician who does not report a measure required to satisfy the quality performance category submission criteria, we proposed that the MIPS eligible clinician would receive zero points for that measure. For example, a MIPS eligible clinician who is able to report on six measures, yet reports on four measures, would receive two “zero” scores for the missing measures.” See https://www.federalregister.gov/d/2016-25240/p-3513.

If you choose to report more than 6 quality measures, then the measures with the highest points assigned with be used: “If a MIPS eligible clinician elects to report more than the minimum number of measures to meet the MIPS quality performance category criteria, then we will only include the scores for the measures with the highest number of assigned points, once the first outcome measure is scored, or if an outcome measure is not available, once another high priority measure is scored.” See https://www.federalregister.gov/d/2016-25240/p-3623.

All measure results submitted will become public information: “[W]e are finalizing our proposal to report on Physician Compare the final score for each MIPS eligible clinician, performance of each MIPS eligible clinician for each performance category, and to periodically post aggregate information of such data. Accordingly, we are finalizing § 414.1395(a), which provides that for public reporting of an eligible clinician's MIPS data in that for each program year, we will post on a public Web site, in an easily understandable format, information regarding the performance of MIPS eligible clinicians or groups under the MIPS.” See https://www.federalregister.gov/d/2016-25240/p-4762. See also 81 FR 77394, available at https://www.federalregister.gov/d/2016-25240/p-4767. (“[W]e proposed to make all measures under the MIPS quality performance category (81 FR 28184) available for public reporting on Physician Compare (81 FR 28291). This would include all available measures reported via all available submission methods, and applies to both MIPS eligible clinicians and groups.” Proposed policy finalized at 81 FR 77395, available at https://www.federalregister.gov/d/2016-25240/p-4781).

If you report less than 6 measures, you’ll be scored on whatever is submitted, and receive zero points for any measure that could have been reported but was not: “Previously in PQRS, EPs had to meet all the criteria or be subject to a negative payment adjustment. However, we proposed that MIPS eligible clinicians receive credit for measures that they report, regardless of whether or not the MIPS eligible clinician meets the quality performance category submission criteria.” See https://www.federalregister.gov/d/2016-25240/p-3513; “After consideration of the comments, we are finalizing at § 414.1380(b)(1)(vi) that MIPS eligible clinicians who fail to report a measure that is required to satisfy the quality performance category submission criteria will receive zero points for that measure.” See also https://www.federalregister.gov/d/2016-25240/p-3524.  

You can receive bonus points in the quality category, but these bonus points are capped at 10%: [W]e are increasing the cap for high priority measures from 5 percent to 10 percent of the denominator (total possible points the MIPS eligible clinician could receive in the quality performance category)  of the quality performance category for the first 2 years.” See https://www.federalregister.gov/d/2016-25240/p-3561/.

To receive bonus points, the reporter must submit at least one scored high priority measure: “The MIPS eligible clinician can receive bonus points on all high priority measures submitted, after the first required high priority measure submitted, assuming these measures meet the minimum case size and data completeness requirements...” See https://www.federalregister.gov/d/2016-25240/p-3550; see also 81 FR 77292 https://www.federalregister.gov/d/2016-25240/p-3529 (“We noted that a MIPS eligible clinician who submits a high priority measure but had a performance rate of 0 percent would not receive any bonus points. MIPS eligible clinicians would only receive bonus points if the performance rate is greater than zero.”)

If you do not submit 6 measures, due to lacking availability of measures, you can still receive bonus points: “The MIPS eligible clinician can receive bonus points on all high priority measures submitted, after the first required high priority measure submitted, assuming these measures meet the minimum case size and data completeness requirements even if the MIPS eligible clinician did not report all 6 required measures due to lack of available measures.” See https://www.federalregister.gov/d/2016-25240/p-3550.

Measures that receive bonus points must be reported with at least 20 instances, and meet the data completeness standard, which for registries is 50% of all encounters reported, with 1 Medicare Part B FFS patient included:  “Bonus points are also available for measures that are not scored (not included in the top 6 measures for the quality performance category score) as long as the measure has the required case minimum and data completeness.” See https://www.federalregister.gov/d/2016-25240/p-3529.

Bonus points will be awarded on all reported measures that hit the 20 case minimum and the data completeness standard - both including the original 6 reported and any additional measures reported: “Bonus points are also available for measures that are not scored (not included in the top 6 measures for the quality performance category score) as long as the measure has the required case minimum and data completeness.” See https://www.federalregister.gov/d/2016-25240/p-3529.

Each outcome or patient experience measure reported in addition to the required high priority measure will receive 2 bonus points: “[W]e are finalizing at § 414.1380(b)(1)(xiii) our proposal to award 2 bonus points for each outcome or patient experience measure ... that is reported in addition to the 1 high priority measure that is already required to be reported under the quality performance category submission criteria.” See https://www.federalregister.gov/d/2016-25240/p-3553.

Each high priority measure reported in addition to the required high priority measure will receive 1 bonus point: “[W]e are finalizing at § 414.1380(b)(1)(xiii) our proposal to award ... 1 bonus point for each other high priority measure that is reported in addition to the 1 high priority measure that is already required to be reported under the quality performance category submission criteria.” See https://www.federalregister.gov/d/2016-25240/p-3553.

The cap for bonus points earned via end to end electronic reporting is 10%: “[W]e are increasing the cap for using CEHRT for end-to-end reporting from 5 percent to 10 percent of the denominator of the quality performance category (total possible points for the quality performance category) for the first 2 years.” See https://www.federalregister.gov/d/2016-25240/p-3598.

The cap for end to end electronic reporting is distinct from the cap for reporting additional high priority measures: “MIPS eligible clinicians will be eligible for both the CEHRT bonus option and the high priority bonus option with separate bonus caps for each option.” See https://www.federalregister.gov/d/2016-25240/p-3598.

You can only earn the end to end electronic reporting bonus if reporting via qualified registries, QCDRs, EHRs, or the CMS Web Interface, and end to end electronic reporting is utilized: “We are finalizing that the CEHRT bonus would be available to all submission mechanisms except claims submissions. Specifically, MIPS eligible clinicians who report via qualified registries, QCDRs, EHR submission mechanisms, and CMS Web Interface in a manner that meets the end-to-end reporting requirements may receive one bonus point for each reported measure with a cap as described.” See https://www.federalregister.gov/d/2016-25240/p-3599.  

Each measure reported via end to end electronic reporting will receive 1 bonus point: 77298 “After consideration of the comments, we are finalizing at § 414.1380(b)(1)(xiv) one bonus point is available for each measure submitted with end-to-end electronic reporting for a quality measure under certain criteria described in this section.” See https://www.federalregister.gov/d/2016-25240/p-3598.  

To calculate the quality category final score, bonus points are added to the score of the initial measures, divided by the total possible points, and then that number is multiplied by 60: “We will sum the points assigned for the measures required by the quality performance category criteria plus the bonus points and divide by the weighted sum of total possible points. The quality performance category score cannot exceed the total possible points for the quality performance category.” See https://www.federalregister.gov/d/2016-25240/p-3623; see also 81 FR 77276-7, available at https://www.federalregister.gov/d/2016-25240/p-3375.; see also 81 FR 7300-1, available at https://www.federalregister.gov/d/2016-25240/p-3631 (examples of scoring calculation).

The weighting for the Quality category is 60%: “Therefore, we are finalizing at § 414.1330(b) for MIPS payment years 2019... 60 percent … of the MIPS final score will be based on performance on the quality performance category.” See https://www.federalregister.gov/d/2016-25240/p-1164.

I know you don’t want to hear this, but it’s already July. And, unfortunately, that means we’re already over 6 months into the first performance year for MIPS. Hopefully, you’re feeling more comfortable with basic MIPS requirements. If not, check out these additional blogs (here, here and here), plus our webinar. But, assuming you’ve got the basics down, you’re now probably wondering how all that reporting translates into your payment adjustment. Well, you’ve come to the right place.

No big surprise here, but MIPS scoring is extremely complicated. I’ve broken it down to the simplest explanation I can muster, but that still involves a few separate blog posts. In this post we’ll discuss the fundamentals of MIPS scoring, as it applies to registry reporting, since pMD is a CMS certified MIPS Registry. Keep an eye out for the next installations of this post, where I’ll explain each individual MIPS categories’ scoring guidelines: Quality Scoring (Part 2), Improvement Activities Scoring (Part 3), and Advancing Care Information scoring, tying it altogether with an overview of the MIPS payment adjustment calculation (Part 4).

Got it?  Then, Ready?  Set.  Go!

MIPS Scoring, Simplified: The Fundamentals  

At the end of the day, the piece of the MIPS puzzle that everyone is most interested in is the payment adjustment. The payment adjustment determines how much of your money CMS will keep and, ideally, how much additional payment you will receive from CMS. Your MIPS payment adjustment is calculated based on your MIPS final score. So, let’s start with how the final score is calculated.

What are the basic components of my MIPS Final Score?

The final score for the 2017 performance year is composed of three different categories, each of which contribute a certain percentage to the MIPS final score. Quality, which replaces PQRS, contributes 60% of the MIPS final score. Advancing Care Information, which replaces the Medicare EHR Incentive program for eligible professionals, typically contributes 25% of the MIPS final score. Finally, Improvement Activities, a brand new program from CMS, contributes 15% of the MIPS final score.

 


Image: Centers for Medicare and Medicaid Services

That means each individual category receives a score, which is then weighted and combined to get the MIPS final score. We’ll look at each individual category’s score calculation in subsequent blog posts, but for now, let’s review some other fundamental questions of MIPS scoring.

Is my payment adjustment applied to all of my billing? Or just to my Medicare Part B billing?

Even though MIPS requires that you report measures on all your patients – not just your Medicare Part B patients – your MIPS payment adjustment is only applied to your Medicare Part B billing. Phew!  

What year will my payment adjustment be applied to?

MIPS payment adjustments are applied two years after the performance period. That means that any payment adjustment you earned in the 2017 performance period will be applied to your Medicare Part B billing in 2019.

Whose billing is the payment adjustment applied to?

For MIPS, the payment adjustment will be applied to the billing of the TIN/NPI, no matter how the TIN/NPI reported data during the performance period. For registry reporting, a practitioner can report either as a group or as an individual. But, no matter which method you choose, the payment adjustment will be applied to your individual TIN/NPI’s Medicare Part B billing.

What happens if I change employers, or if my TIN dissolves?

For MIPS, the assigned payment adjustment will actually follow the NPI – no matter what TIN is associated with your NPI’s billing. This is a huge change from PQRS, and while it has concerning implications, it also closes one of PQRS’ biggest loopholes.

What if I bill under multiple TINs?

If all of your TINs participate in registry reporting, where the only two options for reporting are either individual or group, then only the highest score will be applied to the NPI. So let’s say you moonlight at a hospital that collects and submits MIPS measures on your behalf. This submission will generate one MIPS score associated with your NPI and the hospital’s TIN. If you also have a daily primary care practice, and submit MIPS measures for your private practice, you will receive a MIPS score associated with your NPI and your private practice’s TIN. For the payment adjustment, CMS will apply whichever score was higher to both TINs associated with your NPI.

Ok, now you’ve got the fundamentals down! Stay tuned for Part 2, where we’ll discuss how the Quality and Improvement Activities sections are scored. And as always, if you have any questions or would like to find out more about our MIPS registry, give us a call! To find out more about pMD's suite of products, which includes charge capture, secure messaging, and care coordination software and services, please contact pMD.

References:

  • Components of MIPS Final Score:  “We are finalizing that for the first MIPS payment year (2019), the quality performance category will account for 60 percent of the final score and the cost performance category will account for 0 percent of the final score…” See https://www.federalregister.gov/d/2016-25240/p-3803; see also Table 29 in the Final Rule https://www.federalregister.gov/d/2016-25240/p-3804; see also 2017 MIPS Performance graph at https://qpp.cms.gov/mips/quality-measures.   

  • MIPS requires reporting on all patients, not just Medicare Part B FFS patients:  “Individual MIPS eligible clinicians or groups submitting data on quality measures using QCDRs, qualified registries, or via EHR must report on at least 50 percent of the MIPS eligible clinician or group's patients that meet the measure's denominator criteria, regardless of payer for the performance period.” See https://www.federalregister.gov/d/2016-25240/p-1488

  • The MIPS payment adjustment is only applied to your Medicare Part B FFS billing:  “Specifically, MIPS payment year is defined at § 414.1305 as a calendar year in which the MIPS payment adjustment factor... are applied to Medicare Part B payments.” See https://www.federalregister.gov/d/2016-25240/p-3328

  • The MIPS payment adjustment from the 2017 performance year will be applied to 2019 billing:  “Further, we are finalizing our proposal to use performance in 2017 as the performance period for the 2019 payment adjustment. Therefore, the first performance period will start in 2017 and consist of a minimum period of any 90 continuous days during the calendar year in order for clinicians to be eligible for payment adjustment above neutral. Performance in that period of 2017 will be used to determine the 2019 payment adjustment.” See https://www.federalregister.gov/d/2016-25240/p-160.

  • Even when reporting as a group, the MIPS payment adjustment will be applied to the individual’s TIN/NPI billing:  “A TIN/NPI may receive a final score based on individual, group, or APM Entity group performance, but the MIPS payment adjustment would be applied at the TIN/NPI level.” https://www.federalregister.gov/d/2016-25240/p-3871.

  • The MIPS payment adjustment will be applied to the NPI, even if the TIN changes between the performance year and the payment year:  “[W]e are finalizing our policy to use the TIN/NPI's historical performance from the performance period associated with the MIPS payment adjustment, regardless of whether that NPI is billing under a new TIN after the performance period.” See https://www.federalregister.gov/d/2016-25240/p-3908.

  • If an NPI reports under multiple TINS, the highest score associated with the NPI will be used to determine and apply the MIPS payment adjustment:  “Therefore, we are finalizing our alternative policy to use the highest final score associated with an NPI from the performance period.” See https://www.federalregister.gov/d/2016-25240/p-3901.


Image: Dr. Thomas Albini

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PQRS vs MIPS, quality program differences

As March 31st looms on the horizon, we've been hard at work shepherding our PQRS Registry participants towards successful quality reporting. That means we spend a lot of time analyzing data, reviewing measure selections, and answering basic questions about the PQRS program. One consistent pattern we’ve seen is confusion between 2016’s PQRS reporting program and 2017’s MIPS Quality reporting program. It’s understandable: in 2017 MIPS Quality will completely replace PQRS. To help alleviate the confusion, I’ve gathered together 8 main differences between PQRS and the MIPS Quality program.

1. Bonus and Penalty Structure:
PQRS is a stand-alone program. In 2016, failure to satisfactorily report PQRS results in an automatic 2% penalty to your 2018 Medicare billings. But, PQRS also overlaps with a variety of other CMS programs like MAV, VM, and MU. Most of these other programs also carry their own penalty or bonus, so figuring out exactly what’s at stake for one reporting period is complicated. For 2017, CMS has attempted to streamline these various programs. The 2017 MIPS Quality program is actually one part of the bigger MIPS program. So, participants in the MIPS Quality program will only have one overall MIPS penalty or bonus, rather than separate bonuses or penalties for each distinct program.

2. Who Is Required to Report Quality Measures:
For PQRS, everyone that had submitted a bill on a patient to Medicare Part B Fee For Service in 2016 needed to report quality measures if they wanted to avoid the automatic 2% penalty. For MIPS Quality reporting, not everyone that bills Medicare Part B Fee For Service will need to report. For example, the low threshold exception exempts participants who have less than $30,000 worth of Medicare Part B Fee For Service bills, or who have less than 100 Medicare Part B Fee For Service patients. Additionally, certain types of Advanced Payment Models are exempted from MIPS Quality reporting. Finally, participation in a certain other types of Advanced Payment Models means that participants can skip MIPS reporting - including MIPS Quality reporting - altogether.

3. Reporting Time Period:
To avoid an automatic penalty in PQRS, the program required that quality measures be reported for the full performance year, January 1st to December 31st. With MIPS - at least for 2017 - participants can avoid an automatic penalty as long as they report on something for some time period. Though, participants should keep in mind that this relaxed time frame for reporting period will change in 2018 and beyond, eventually once again requiring a full year's reporting.

4. Reporting Population:
PQRS requires that participants report on at least 50% of the Medicare Part B Fee For Service patients who qualify for the chosen quality measures. MIPS requires that participants report on at least 50% of all patients who qualify for the chosen quality measures, regardless of payer.

5. Number of Quality Measures Required to Report:
PQRS requires participants to report at least 9 quality measures. MIPS requires participants to report on 6 quality measures.

6. Structure of Required Quality Measures:
PQRS requires that the quality measures participants choose to report span across 3 domains, which are like categories of effective healthcare. MIPS only requires quality measures to be reported, they do not have to be chosen from any specific categories.

7. Cross-Cutting Measures vs. Outcomes Measures:
PQRS requires that the quality measures reported by participants include one cross-cutting measure, unless a special exception applies. MIPS does not require cross-cutting measures, but rather requests that the quality measures reported by participants include one outcomes measure.

8. Measure Groups:
PQRS allowed participants to utilize measure groups reporting as an alternative way to satisfactorily report quality measures; MIPS does not allow for measure groups reporting.

And, finally, one bonus difference plus similarity...

Still a Four Letter Word, Just a Different One:
PQRS means the “Physician Quality Reporting System” and MIPS is the “Merit-Based Incentive Payment System.” Thus far, despite efforts by CMS to ease the burden of quality reporting, both programs have caused frustration, anxiety and struggle for many of those involved.
As I've worked with several health systems on how they have been handling PQRS reporting and how they intend to report MIPS quality data to CMS, I've seen some things that I can't unsee: the thick binder overflowing with handwritten pages describing various quality measures; the room full of data entry personnel busily reading patient charts; the EHR screens packed with data fields for a physician group that turned on every single outpatient quality measure.

"We'll capture them all up front, then we'll figure out which ones to submit to CMS later," they said. But it turned out that they were having a hard time convincing physicians to go into that EHR screen at all because it was so heinous. Hence the room full of data entry folks.

MIPS is complicated to begin with; and for complicated health systems, it can get REALLY complicated. They have physicians reporting under multiple Tax ID Numbers (TINs), and often many completely different specialties that ended up sharing a single TIN. Assuming they're reporting as a group (GPRO), that means they often pick "lowest common denominator" measures centered around primary care. This burdens their already-overworked Primary Care Providers with additional data entry, and it effectively excludes many hospitalists, surgeons, and other specialists from quality reporting - certainly from any quality metrics that matter to them.

But with ever-increasing risk from mandatory bundled payments, Accountable Care Organizations and other advanced payment models, and the upcoming cost component of MIPS, I'm hearing from more and more of these enterprises that they can no longer afford to make quality something that only the Primary Care Providers and care coordinators worry about. It's something that involves the specialists too - for example, if a hospitalist fails to talk with a patient about their advance care planning, that patient could end up receiving a very costly and unpleasant intervention that perhaps they didn't want. Getting buy-in from the specialists, and giving them a way to measure their success on these metrics, is vital.

Thinking back to the room full of data entry specialists reading charts, I'm struck by the gap between the ostensible intention of these quality programs (improve the quality of care by rewarding physicians who follow evidence-based care) versus their result (the physicians are not engaged, and the hospital suffers additional costs to hire a room full of people to read their charts and enter data into a registry). There is a better way to engage specialists in quality programs and to actually improve outcomes in the process, but it has to meet them where they are - which is not necessarily sitting in front of a computer - and it has to offer them targeted measures that are relevant to their specialty, not just smoking cessation.

At pMD, we say: bring it on! We love working with specialists of all kinds, and we've developed some innovative tools that help with measure selection and targeted mobile data capture during hospital rounds and immediately after surgeries. There is no one-size-fits-all solution for MIPS, but the future is bright for organizations that embrace their own complexity and find a nuanced solution that will work for them and their physicians.
To run a health care practice, it’s crucial to have the right information to navigate through the many government changes. So I’ve put together a MIPS For Dummies, of sorts. My goal is to give you some insight into the quickly approaching government changes to the reimbursement process. The Centers for Medicare & Medicaid Services (CMS) has released some preliminary information and here is what we know.

Let’s start with the basics. What does MIPS stand for?
Monkey-Identified Petite Scoliosis. Just kidding! MIPS is the Merit-Based Incentive Payment System and it is a new value-based payment model. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is the statute that created this new advancement of the value-based payment model.

What is MIPS?
MIPS is a new payment system outlining financial incentives (and penalties) based on the data submitted by practices, which judges the quality, outcomes, and efficiency of patient treatment. Imagine that the Value-Based Modifier Program, Physician Quality Reporting System (PQRS), and the Medicare Electronic Health Record (EHR) all met and joined forces under one larger, combined program.

Who is at the mercy of MIPS?
Perhaps you, if you’re reading this blog post. But really, MIPS reporting will be required for any clinician billing for professional services under Medicare Part B. This includes all physicians, dentists, chiropractors, physician assistants, physical or speech therapists, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and hospital-based eligible providers. Providers who are in their first year of Medicare or are below the low-volume threshold may not be required to participate in MIPS.

When is MIPS currently scheduled to roll out?
January 1, 2017! This time I’m not kidding…

Finally, here are some fun facts about MIPS:
1. Centers for Medicare & Medicaid Services (CMS) is no longer accepting comments on the proposed rule - The cut off date was June 27, 2016. However, the final rule with comment period was issued on 11/4/16, and you can comment on that for only a few more days! Cut off for the comment period for this version of the rule is 12/19/16.

2. Qualifying Advanced Alternative Payment Model (APM) Participants are eligible clinicians who are exempt from the MIPS model. This includes Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models.

3. CMS released a fancy new (and surprisingly helpful!) website that guides practices through how to participate in each category of MIPS.

4. To participate in the ACI portion of MIPS you will need a 2014 or 2015 Edition Certified EHR before or on January 1, 2017.

5. If you're eligible for MIPS but decide not to participate in the program, you will receive an automatic negative 4% payment adjustment on your 2018 Medicare reimbursements. (This one is a not-so-fun fact).

Now, last but not least, pMD’s web portal can produce reports reflecting valuable quality data that can be leveraged for MIPS reporting, PQRS solutions and other government changes.

#MIPTASTIC #MIPSYALL #MIPSYEAH
One of pMD’s mottos is to work like a beautifully engineered German car: fast, fun, and efficient. As pMD’s in-house attorney, I’m often pulled in the polar opposite direction as I wade through dry, convoluted, acronym-heavy health care regulations. It takes no stretch of the imagination to realize that government health care regulations are not fast, fun, nor efficient. So, one of my favorite challenges is to take this complicated regulatory jargon and break it down to easy to understand language. This week’s challenge: MACRA, QPP, MIPS, and APMs.

What is MACRA?

MACRA is the acronym for a federal law that is officially titled the “Medicare Access and CHIP Reauthorization Act of 2015.” MACRA was touted as the largest health care bill to pass since the Affordable Care Act was signed into law in 2010, and had impressive bipartisan support. MACRA made several changes to existing health care laws, including restructuring Medicare payments. Thus, the law is the newest solution to the ongoing challenge of shifting Medicare payments from fee-for-service to value based. MACRA created the newest evolution of the value based payment model.

This newest evolution, as proposed by CMS last week, is called the Quality Payment Program, or QPP. The Quality Payment Program officially ends and replaces the controversial Sustainable Growth Rate (SGR) payment formula and combines existing value based payment formulas to create a new framework. The QPP offers two distinct paths to payment:

1. Merit Based Incentive Payment System (MIPS); and
2. Alternative Payment Models (APMs).



What is MIPS?
MIPS consolidates three of CMS’s current value based payment programs. Those three programs are:

1. Physician Quality Reporting System (PQRS);
2. Meaningful Use; and
3. Value Based Modifiers.

CMS aims to fully dissolve these programs and replace them with MIPS by 2019. The MIPS framework will use these programs as a reference point to award composite scores to each provider. There are four factors influencing the composite score:

1. Quality;
2. Advancing Care Information (formerly Meaningful Use);
3. Clinical Practice Improvement Activities; and
4. Cost or Resource Use.

Each category is weighted differently, with quality as the most influential factor. Small practices can combine to report as a “virtual group” and be scored together on combined performance.

The current timeline is to begin measuring MIPS in calendar year 2017, which will influence payments in calendar year 2019. Potential bonuses for high scoring practices range from 4% in 2019 to 9% in 2022. Additionally, $500M has been set aside to potentially be awarded as “exceptional performance” bonuses. Low scoring practices will see equivalent percentage based fee reductions. Standard fee schedule updates will remain flat from 2019 to 2025, when a yearly 0.25% increase will begin for MIPS participants.

CMS believes that most providers will begin their QPP participation on the MIPS pathway, and then gradually transition towards the APM pathway. Indeed, CMS has created certain incentives to encourage providers to move towards substantial involvement in an APM.

What is an APM?

The second path to payment offered by QPP is participating in an alternate payment model, or APM. Providers participating in the APM pathway can avoid the reporting mechanisms required by MIPS, and still be eligible for financial bonuses. CMS hopes that eventually a majority of providers will participate in APMs, and thus has further incentivized this pathway within the QPP. However, exactly which organizations qualify as APMs is still unknown. Familiar organizations such as Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are currently considered to be included. But, MACRA charged CMS with creating an APM certification process so that innovative health care solutions can become certified APMs under the QPP.

CMS’s goal is to begin payout of a flat 5% fee increase in calendar year 2019 for all APM participants. As with MIPS, standard fee schedule updates will remain flat from 2019 to 2025, but unlike MIPS, a yearly 0.75% increase will begin for APM participants in 2026.

What does this all mean?

Ultimately, it means that Medicare payment models are changing… again. But, the exact requirements necessary to earn these payments is still open for debate. So, the ultimate outcome of the legislation and how much closer on the path to value it will bring our health care system remains to be seen.

All this brings me to the plainest, simplest summary of MACRA, QPP, MIPS, and APMs I can muster:

MACRA is a law. The QPP is the newest evolution of a value based payment model, which offers two distinct payment programs: MIPS and APMs. The QPP was created by MACRA.

The exact implementation plans for MACRA and the QPP takes us back to the world of dry, convoluted, acronym-heavy health care regulations. But, that’s another blog post. At the end of the day, Medicare payment changes once again hover on the horizon. And while pMD can’t advise our charge capture customers on complying with these regulatory payment issues, we can – and do – create fast, fun, and efficient tools to help them propel medical practices through the ever-changing regulatory landscape to success.

One thing that we can predict with certainty in the health care industry is new acronyms. And new acronyms can mean changes to CMS payment programs. It was approximately one year ago that my colleague Elise wrote a great article on the Physician Quality Reporting System (PQRS). PQRS was originally an incentive based program which, in 2006, included a 1.5% incentive payment based on total allowable charges to providers who reported quality information to CMS. In 2008, the Medicare Improvement for Patients and Providers Act (MIPPA) extended PQRS and increased the incentive to 2%.

This incentive continued until 2010 when the Affordable Care Act (ACA) introduced penalties for providers who did not submit PQRS data. The introduction of penalties forced providers to rethink how they were submitting PQRS data in order to ensure they wouldn't see their levels of reimbursement decline. Participating providers were forced to adopt additional software solutions, employ additional specialists, or join PQRS registries (like us!) in order to not be penalized.

Fast forward to 2016, and after 13 years and over $150 billion spent, the Sustainable Growth Rate (SGR) formula is being eliminated! The Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law by the President on April 16, 2015 and completely revamps how CMS pays providers.

According to MACRA, we are now in a transition period whereby:

• Physicians will receive annual growth fee schedule rate increases of 0.5% starting on July 1st, 2015 through the end of 2018.
• There will be a 2% penalty for failure to report PQRS measures.
• There will be a 3% penalty for failure to meet meaningful use requirements.
• The rates in 2019 will be effective through 2025 and providers will have the opportunity to receive additional payments through the 'Merit-Based Incentive Payment System' (MIPS).

Compare the MIPS incentive payments to the SGR formula of a 21% cut in reimbursement, and you can see why the American College of Physicians is in complete support of MACRA and MIPS.

The most surprising provision in MACRA, however, is the fact that CMS is now required to replace not only the SGR, but also PQRS, the Electronic Medical Record Incentive Program (Meaningful Use), and the Value Based Modifier program by 2019 with MIPS.

The AMA and the ACP both agree that the MIPS program is a positive development for physicians as it allows them to effectively determine their eligibility for incentive payments beginning in 2019.

pMD is getting set to help our providers proactively set their performance goals and get credit where credit is due! Check back for part two on MIPS where I describe how pMD helps our providers in the four MIPS assessment categories which will be crucial to receiving positive MIPS adjustments in 2019.