Performance and Reimbursement under MIPS for Orthopedics
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The document discusses the Merit-Based Incentive Payment System (MIPS) under MACRA, focusing on its components, scoring methodology, and operational considerations for physicians. It highlights the importance of understanding MIPS performance categories, estimating composite scores, and choosing effective measures to maximize reimbursement. Key recommendations include educating staff, optimizing quality metrics, and utilizing available resources for performance monitoring.
Performance and Reimbursement under MIPS for Orthopedics
- 1. PERFORMANCE AND REIMBURSEMENT UNDER MIPS Karen R. Clark CPHIMS,FHIMSS Chief Information Officer OrthoTennessee
- 2. KAREN R. CLARK, MBA, CPHIMS, FHIMSS Karen R. Clark is chief information officer for OrthoTennessee, where she has worked since 1998. In that role, she serves on national committees for the Healthcare Information Management Systems Society (HIMSS). A HIMSS Fellow and Certified Professional in Healthcare Information and Management Systems, she previously ran her own business, Network & Systems Consulting.
- 3. DISCLAIMERS • Information here is based on the Final Rule published Oct.14, 2016 • CMS issues FAQ and changes • Summaries like this one omit important detail • The scoring methodology requires study to be fully understood • This presentation focuses on MIPS only • This presentation does not cover Alternative Payment Models, eligibility, or exemptions • Some graphics/table credits to CMS
- 4. PUBLIC AWARENESS • Deloitte 2016 Survey of US Physicians • 50% of non-pediatrician physicians had never heard of MACRA • 32% recognized the name, but are not familiar with details • 21% of self-employed physicians reported some level of familiarity • 9% of employed physicians reported the same • Survey: http://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/macra.html
- 5. TODAY’S PRESENTATION • MACRA Basics • MIPS Components and Scoring • Operational considerations • Choosing the best measures • How to estimate your composite score • Methods to maximize your score • Evaluating CMS “flexibility” on reporting
- 7. • Planned increase is only 0.5% for next 5 years. • Only method for larger increase is via MIPS/APM Replaces the Sustainable Growth Rate (SGR) • Physician Quality Reporting System • Meaningful Use • Value Based Modifier • One reporting period for all measures Aligns current independent programs into one • This is called Merit-Based Incentive Payment System (MIPS) Adjusts FFS payments up or down based on a “composite score” • Beginning in 2017 these reporting programs are fully merged into the payment calculation Until MIPS, participation in MU and PQRS was optional • Specialty measure sets for orthopedics • Self-select your peers Specialty organizations have a role in measure development
- 8. TIMELINE Oct 14, 2016 • Publication of Final Rule (Federal Register 11/1/16) Jan. 1, 2017 • PFS adjustments based on 2015 performance (PQRS/MU/VBM) • MIPS performance period begins Jan 1, 2018 • PFS adjustments based on 2016 performance • MIPS second performance period begins Jan 1, 2019 • PFS adjustments for MIPS (-4/+14) based on 2017 performance
- 9. MIPS COMPONENTS AND SCORING Brief Overview
- 10. MIPS PERFORMANCE CATEGORIES Quality Resource Use Advancing Care Information Practice Improvement Activities Performance in each category is combined to arrive at a clinician’s “composite score.”
- 11. ELEMENTS OF THE COMPOSITE SCORE ARE WEIGHED DIFFERENTLY 60% 45% 30% 0% 15% 30% 15% 15% 15% 25% 25% 25% Advancing Care Information Practice Improvement Activities Quality Resource Use 2017/2019 2018/2020 2019/202 1
- 12. POINTS FOR EACH MEASURE ARE BASED ON PERFORMANCE Decile 1 2 3 4 5 6 7 8 9 10 Points 1.0-1.9 2.0-2.9 3.0-3.9 4.0-4.9 5.0-5.9 6.0-6.9 7.0-7.9 8.0-8.9 9.0-9.9 10 CMS publishes deciles based on national performance in a baseline period (2-years prior to the performance period). Eligible clinician’s performance is compared to the published decile breaks. Points are assigned based on which decile range the performance data is located. All scored measures receive at least 1 point. 7% 16% 23% 36% 41% 62% 69% 79% 85% A performance rate of 20% would earn 3.5 points. A performance rate of 80% would earn 9.5 points. Quality Component Score (out of 100)=(Total Measure Points + Bonus Points)/Possible Points
- 14. COMPOSITE SCORE CALCULATION • Component X Weight = Score • ACI points X 25% = ACI Score • Quality points X 60% = Quality Score • PIA Points X 15% = CPIA Score • Resource Use X 0% = Resource Use Score Total Composite Score
- 16. QUALITY COMPONENT • More specialty measures • Review specifications carefully Measures are published in the Final Rule • 1 Outcome measure Clinicians report on 6 measures • Validate specifications with your EHR vendor Likely similar to many of your current PQRS measures • N.B. if you’ve been doing well based on 50% reporting Reporting requirement moves from 50% of patients to 90%
- 18. RESOURCE USE (COST) COMPONENT Based on Medicare cost of attributed patients Includes 40+ cost measures to account for specialties No reporting requirements Look at your 2015 QRUR* Report to see your current cost score Calculation shifting to episodes *Quality and Resource Use Report
- 19. ADVANCING CARE INFORMATION Rebranded Meaningful Use
- 20. MU ACI ADVANCING CARE INFORMATION VS. MEANINGFUL USE
- 21. ADVANCING CARE INFORMATION REQUIRED MEASURES Security Risk Analysis Electronic Prescribing Patient Electronic Access (Patient Portal) Request/Acc ept Summary of Care Send Summary of Care
- 22. ADVANCING CARE INFORMATION SCORING • Accounts for 50 points of the total Advancing Care Information category score. • Clinicians must provide numerator/denominator or yes/no for each objective and measure. Base Score: • Accounts for up to 80 points towards the total Advancing Care Information category score • The total score can exceed 100 points, but anyone who scores 100 points or above will receive the full credit of the maximum 25 points • Physicians and other clinicians select the measures that best fit their practice Performance Score: Clinicians must be able to report “yes” to the Protect Patient Health Information objective
- 23. ADVANCING CARE INFORMATION SCORING
- 25. PRACTICE IMPROVEMENT ACTIVITIES 8 categories of CPIA activities Each activity is defined as “medium” or “high” value Medium value activities earn 10 points High value activities earn 20 points Clinicians report on four medium or two high-weighted activities for 2017 Receive credit for things practice already doing
- 26. CLINICAL PRACTICE IMPROVEMENT ACTIVITIES AND MEASUREMENT STUDY • The Centers for Medicare & Medicaid Services (CMS) is conducting a study to investigate the burdens associated with quality performance data collection and submission processes.The study aims to: • Examine clinical workflows and data collection methods using different submission systems, • Understand the challenges clinicians face when collecting and reporting quality data, and • Make future recommendations for changes that will attempt to eliminate clinician burden, improve quality data collection and reporting, and enhance clinical care. • Merit-based Incentive Payment System (MIPS) eligible clinicians and groups that participate successfully in the study will receive the full credit for the MIPS Improvement Activities performance category. Non-eligible clinicians are also welcome to apply.
- 27. PRACTICE IMPROVEMENT ACTIVITY CATEGORIES Expanded Practice Access Population Management Care Coordination Beneficiary Engagement Patient Safety Health Equity Emergency Preparedness and Response Behavioral/Mental Health
- 28. PIA FOR ORTHOPEDICS Most CPIA activities are primary care focused • Collection of patient satisfaction data (medium) • Providing specialist reports back to referring (medium) • Participation in an HIE (medium) • Consultation of a Prescription Drug Monitoring Program prior to prescribing Schedule II (high) Some examples for orthopedics: This is a place where you should get the full 40 points Reporting is by attestation-be careful to document for audits
- 29. OPERATIONAL CONSIDERATIONS Putting it into practice
- 30. CHOOSING THE RIGHT MEASURES Choosing measures requires a strategic approach Meaningful Use had set targets For PQRS, simply reporting met one requirement Some practices chose measures based on their minimal impact to clinicians • Reporting by Tax ID allows you to take advantage of sub-specialists Look at the total score • That have the maximum weighting • Are achievable • Where you believe you can affect the result For 2017, choose measures:
- 31. DIFFERENT WAYS TO SCORE Performance Category Score Weight Weighted Score Quality 3 60% 3 Resource Use 0 0% 0 CPIA 50% 15% 7.5 Advancing Care Information 50 25% 12.5 Composite Performance Score (Subtotal x 100) 23 points Performance Category Score Weight Weighted Score Quality 56 60% 56 Resource Use 0% 0 CPIA 100 15% 15 Advancing Care Information 0 25% 0 Composite Performance Score (Subtotal x 100) 71 points Eligible Clinician Submits only 1 Quality Measure – no payment adjustment Eligible Clinician Submits data in all 3 categories Credit: CMS
- 32. FORECASTING MIPS IMPACT ON REVENUE
- 33. EVALUATING YOUR RISK Determine amount of revenue that will be affected Calculate possible upward and downward adjustments Choose measures for best overall score and set goals Estimate your composite score *Quality and Resource Use Report from CMS
- 34. DETERMINE WHAT IS AT RISK/OR POTENTIAL INCREASE • Base performance level is 3 • Maximum MIPS increase 4% • Maximum MIPS decrease 4% For 2017 only • For scores over 70 • From 0.5% up to 10% • $500,000,000 allocated Exceptional performance bonus • Max penalty -$400,000 • Max increase $1,400,000 $10,000,000 Part B payments • <=$30,000 charges • <=100 patients Low volume exclusion
- 35. CHOOSE MEASURES AND SET GOALS N.B. Choose your reporting option Minimum (1) with no adjustment 90 days for partial adj Full year for moderate adj Plan your 2017 strategy Set measures and goals Establish monthly reporting/feedback loop Determine the optimal mix of measures Leverage existing workflows Set goals using benchmarks Evaluate your PQRS and MU Performance Use your QRUR reports Use your registry report for benchmarking
- 36. 5 THINGS TO DO IN 2017 1. Educate your organization, including senior management 2. Estimate your MIPS payment adjustment using your 2015 MU/PQRS/VBM scores 3. Optimize MU/PQRS/VBM quality to maximize MIPS score 4. Evaluate staff, resources and organization structure needed to be successful 5. Identify the process you will use to monitor performance throughout the year
- 37. RESOURCES • CMS has put out a user-friendly web page with all of this information at https://qpp.cms.gov/ • A bookmarked copy of the Final Rule • HHS Security Risk Assessment Tool: https://www.healthit.gov/providers- professionals/security-risk-assessment
- 38. WATCH CMS NEWS RELEASES FOR CLARIFICATION • Quality measures are key to maximum benefit • Reporting on all 3 MIPS categories is best bet Full year vs. 90 days? • Registry vs EHR vs claims have different benchmarks Examine quality reporting mechanism carefully Pull CMS benchmark data from QPP site
- 40. 40 Streamlining Orthopedic Episodes of Care www.wellbe.me