Clinical Quality Measures for Eligible Providers

 Final Quality Project Part 4: Clinical Quality Measures for Eligible Providers

Overview

This activity focuses on the Quality Payment Program under MACRA (Medicare Access and CHIP Reauthorization Act). The activity uses online resources from the CMS website. This activity focuses on the Merit Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) for the eligible professional.

Resources

Go to the website CMS.gov (Centers for Medicare & Medicaid Services) to complete the following:

1. Watch an introduction to MIPS: https://youtu.be/CN7_gBGXYq4 2. Watch a video about performance categories: https://youtu.be/oTBkl07SRRo

a. Weights changed for 2018: Quality = 50% and Cost= 10% b. Weights changed for 2019: Quality= 45% and Cost= 15%

Background In the past, providers had several quality payment programs that they participated in to receive reimbursement from CMS. These included a Sustainable Growth Rate, Value-For Service (Fee- for-Service), Physician Quality Reporting, Meaningful Use, and Value Based Modifiers. Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), a new Quality Payment Program was instituted that replaced all of the previous programs. Providers are now reimbursed under 1 of 2 programs, the Merit-Based Incentive Payment System (MIPS) or the Advanced Alternative Payment Models (APMs). Depending on a providers eligibility, they will be reimbursed using the metrics provided by the appropriate program. Under the MIPS program, providers are rated on a 100 point scale. Their score will determine reductions or incentives from the standard Medicare payment rate. As MIPS is a recent program, starting on January 1, 2017, the first few years are seen as transitional. For 2017, a minimum of 3 points was required in order to stay neutral and not receive any payment reductions. This raised in 2018 to 15 points to remain neutral and not receive any reductions. This is a two year process, so for those who reported for 2017, CMS reviews the scores and data in 2018, and then adjusts the payments for 2019. If a provider falls below the threshold of 3 points for 2017, they will receive a payment reduction in 2019. The table below shows the payment structure for the first few years:

Year Reported Year Adjusted Maximum Reduction Maximum Increase 2017 2019 -4% +12% 2018 2020 -5% +15% 2019 2021 -7% +21%

2020+ 2022+ -9% +27% There are bonuses available through the program for the first 5 years for the very top performers. If a provider scores 70 or higher in 2017, they are eligible for this bonus. A key factor of the program is that it is “budget neutral”. This means that the money received from reductions is used to provide the incentives. While providers may be eligible for an amount up to the maximum increase, their increase will depend on the amount of funds saved from the reductions in payments. MIPS-Eligible Providers:

• Doctors of Medicine (MD) • Doctors of Osteopathy (DO) • Doctors of Dental Surgery (DDS) • Doctors of Dental Medicine (DMD) • Doctors of Podiatric Medicine (DPM) • Doctors of Optometry (OD) • Doctors of Chiropractic (DC) • Physicians Assistants (PA) • Nurse Practitioners (NP) • Clinical Nurse Specialists (CNS) • Certified Registered Nurse Anesthetists (CRNA)

MIPS-Exempt Providers (will remain under Standard Medicare Payment Rate)

• Those not on the above list (through at least the year 2021) • Provider is in their first year of billing under Medicare (under any entity) • Provide bills ≤$90,000 in Medicare per year • Provide sees ≤200 Medicare patients per year • Providers in an Advanced APM (only those classified as Advanced, see next section)

APMs An alternative payment model gives added incentive payments to high-quality and cost- efficient care. Advanced APMs accept risk based on the quality and effectiveness of care provided like an Accountable Care Organization (ACO). Advanced APMs base payment on quality measures comparable to those in MIPS, require use of certified EHR technology, and bear more than nominal financial risk for monetary losses OR are a Medical Home Model under the CMS Innovation Center Authority. Advanced APMs are not required to report under MIPS due to the cost-sharing and risk structure already in place. Providers in Advanced APMs will instead earn 5% incentive payments in 2020 as long as they receive 25% of Medicare Part B payments of 20% Medicare patients. Quality under MIPS The Quality section under MIPS replaces the Physician Quality Reporting System (PQRS) and the quality component of the Value Based Modifier (VBM) program. While this differs in name, it uses the same measures. Under the MIPS Quality reporting, providers are required to report data on 6 measures or participate in a specialty measure set. This must include 1 outcome based measure or another high priority one if an outcome based measure is not available. CMS will compare the providers performance rate to a national benchmark (which is established by looking at the performance rate for the two prior years). The benchmark is divided into deciles which determines the providers score. An example is provided below: Measure 236: Controlling High Blood Pressure: Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period

Measure 236: Controlling High Blood Pressure (EHR Submission) Decile Quality Measure Benchmarks (%) Possible Points Decile 3 51.46-56.82 3 Decile 4 56.83-60.94 4 Decile 5 60.95-64.67 5 Decile 6 64.68-68.17 6 Decile 7 68.18-72.00 7 Decile 8 72.01-76.25 8 Decile 9 76.26-82.20 9 Decile 10 >=82.21 10

If a provider reports that in 2019 they had 72.5% of patients between 18-85 years old with a diagnosis of hypertension and adequately controlled blood pressure they would receive 8 points towards their MIPS Quality category.

There are 270 quality measures to choose from among two types, outcome and high priority measures. Remember, the provider must choose one outcome measure if applicable. In order to become more applicable to all types of providers, there are currently 34 designated specialty measure sets available including:

• Allergy/Immunology • Anesthesiology • Cardiology • Gastroenterology • Dermatology • Emergency Medicine • Pathology • Mental/Behavioral Health

Activity 1 – Answer the following questions: Determine if the following providers are considered “Eligible Professionals” for MIPS. (Y/N)

1. A Doctor of Medicine (MD) who bills $200,000 in Medicare payments per year 2. A Nurse Practitioner (NP) who has 125 Medicare patients 3. A Doctor of Medicine (MD) who is part of an Accountable Care Organization that meets

Advanced APM status 4. A Physician Assistant (PA) who is a member of an APM, but the APM is not considered

Advanced

Critical Thinking Questions

5. The quality category of MIPS decreased the past two years from 60% down to 45%. The cost category rose from 0% to 15%. What are the implications of this for organizations? Will quality be affected? (*Remember this is the percentage of the score they are graded on, not the facility’s actual score. So they are being graded with less of an emphasis on quality and more of an emphasis on cost*)

6. If providers are hospital based, are they exempt from MIPS? Why?

7. A provider in your organization is upset about the changes to the reimbursement programs. They are upset CMS has imposed an all-new quality payment program that changes everything they were doing previously. They feel this is too much new information to learn. Do you agree? Why?

Activity 2 Now that you have a better understanding of MIPS, address the following scenario: You work for a multi-physician pediatric practice. Your organization is preparing for the next year and you are researching quality measures to address under MIPS.

• Open the MIPS Quality Measures file • Go to tab titled 2019 MIPS Quality Measures List • Scroll to the left to find the Specialty Measure Sets, starting in column T • Locate and Filter the list for Pediatric Specialty Measures • You will notice that there are 22 measures available to choose from.

8. Which measure must we report on as it is an outcome measure? (use the quality

number)

After reviewing the quality measures available you make the decision to choose measures that have previous deciles available so that you can perform a comparison and set a quality plan for the year.

• Open the 2019 MIPS Quality Benchmarks • Select the MIPS Benchmark Results tab • Locate all 22 measures from the previous file in the MIPS Benchmark Results tab

9. Do all 22 Pediatric Specialty Measures have benchmarks to compare against? Your team completed an audit and found the results of several measures for your facility. The results are listed below in the chart. Compare the “% of charts that meet the standard” with the decile scores in the MIPS Benchmark Results tab and determine the decile the facility’s current score falls. Record the decile in the table below, you will use these to answer the next few questions. Some measures will be listed multiple times as they have different submission methods available. If available, use the eCQM method line. If they do not have the ability to use eCQM, use the MIPS CQM method line.

10. Does the facility have at least 5 measures that fall in the 10th decile? The facility’s CEO has determined that the 2 lowest scoring measures need to be addressed with quality improvement plans.

11. Which measure falls into the lowest decile (use quality number in answer)?

12. Which measure falls into the second lowest decile (use quality number in answer)? You will now choose one of these 2 measures to begin with. A meeting has been scheduled to discuss the quality improvement initiative.

13. What is the quality number of the measure you choose to focus on first?

14. Why did you choose to address this measure first?

15. Outline a high-level action plan to take to the meeting. (Must include steps of quality improvement including use of quality improvement tools; this does not have to be an in- depth plan specific to the measure, it only needs to outline the high-level steps of a QI plan.)

Quality Number (Q#)

# of Applicable Charts

# of Charts that meet standard

% of charts that meet standard

Decile

65 70 68 97% 66 30 28 93% 91 55 55 100% 93 55 55 100% 110 395 99 25% 134 200 124 62% 239 395 218 55% 240 395 297 75% 305 25 4 16% 310 50 40 80% 379 395 12 3% 402 75 66 88%