1) MIPS aims to simplify physician benchmarking and scoring by consolidating existing quality reporting programs into a single program called MIPS. It will include measures of quality, clinical practice improvement activities, advancing care information, and resource use.
2) Approximately 95% of providers will participate in MIPS. Scores will be publicly reported, with winners receiving bonuses and penalties funding the bonuses.
3) MIPS scoring involves assigning point values to performance in each category, with the largest weights on quality (50%) and advancing care information (25%). Higher performance will result in positive payment adjustments while low performance may result in penalties.
2. MEMORABLE
FACTOIDS
2
1. ≈95% of providers will participate in MIPS
2. MIPS is budget neutral. Losers’ penalties pay winners’ bonus
3. Congressional Lawmakers sought to “simplify” physician benchmarking
4. AHIP & CMS already agreed to harmonize quality metrics
5. MIPS scores will be publicly available
6. An Advanced Alternative Payment Model (APM) is a generic term to describe 2-
sided risk based arrangements
April 2015
• MACRA
passed via
bipartisan
support
April 2016
• Proposed
Rule Released
November 2016
• Final Rule
Released
January 1, 2017
• Reporting
Year 1 Begins
3. ACRONYM GUIDE
3
ACI – Advancing Care Information (Formerly Meaningful Use)
AHIP – American Health Insurance Plans
APM – Advanced Alternative Payment Model
CCM – Chronic Care Management (CPT 99490)
CERHT – Certified Electronic Health Record Technology
CPIA – Clinical Practice Improvement Activities
CPOE – Computerized Provide Order Entry (E-Prescribing)
CPS – Composite Performance Score
HIE – Health Information Exchange
MACRA – Medicare Access and CHIP Reauthorization Act of 2015
MSPB – Medicare Spending Per Beneficiary
MSSP – Medicare Shared Savings Program
PCMH – Patient Centered Medical Home
SDOH – Social Determinants of Health
TCM – Transitional Care Management (CPTs 99495-6)
QPP - Quality Payment Program
QCDR – Qualified Clinical Data Registry
4. MACRA STATUS
UPDATE 9/8/16
4
1
Test Program: Submit any
data to avoid negative
payment adjustment
2
Participate for part of year
for a “small positive
adjustment”
3
Participate for the entire
year for a “moderate
positive adjustment”
4
Avoid MIPS via Advanced
Alternative Payment Model
(APM)
CMS announced 4
Options for MIPS
Key Take Away: If you can, participate for the entire year.
5. ≈95% PROJECTED TO PARTICIPATE IN MIPS
5
0%
20%
40%
60%
80%
100%
Solo
2-9 physicians
10-24
physicians
25-99
physicians
100+
physicians
MIPS Estimated Economic Impact 2019
% Eligible Clinicians MIPS Penalty % Eligible Clinicians MIPS Bonus
*Estimations prior to
recent update
nullifying negative
penalties in 2019
6. Category Formerly
Known
As:
Year 1
Weight
Scoring Methodology
Quality PQRS 50% • Each measure 1-10 points compared to historical
benchmark
• 0 points for non-reported measure
• Bonus Points available
• Measures are averaged for total categorical
score
Advancing Care
Information
Meaningful
Use
25% • Base score of 50% points achieved by reporting
at least one unique patient for each measure
• Performance score of up to 80% points
• Public Health Reporting Bonus Point
• 100% points = Full Credit
Clinical Practice
Improvement
Activities
N/A 15% • 10 Point “medium weight” activities & 20 Point
“high-value” activities available
• 60 Points = Full Credit
Resource Use Value-
Modifier
10% • Similar Scoring to Quality Category
• No Reporting Necessary!
6
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
Key Take-Away: Quality & ACI Take priority.
MIPS COMPOSITE SCORE SUMMARY
7. QUALITY
PERFORMANCE
Each measure
is converted to
a decile point
scale (1-10)
Zero points for
a non-reported
measure
Bonus points
Total
Points
7
Total Points
Total
Possible
Points
Quality
Composite
Performance
Score
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
8. Decile 1 2 3 4 5 6 7 8 9 10
Possible
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
8
QUALITY
PERFORMANCE
• CMS publishes deciles based on national performance in baseline period
• Eligible clinician’s performance is compared to baseline
• If performance on a measure is clustered together (i.e. 70% of respondents are within 3 deciles,
the midpoint decile will be assigned to all providers in this cluster)
Decile 1 2 3 4 5 6 7 8 9 10
Possible
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
% of
Providers
0% 2% 3% 5% 10% 80%
All 80% of these providers will
receive the midpoint decile of
8 points
9. QUALITY PERFORMANCE-
BONUS POINTS
• Earn up to a possible 10% “extra credit” in bonus points
• 1 bonus point for other “high priority” measures (up to 5%)
• 1 bonus point for each measure reported using CEHRT (up to
5%)
• 2 bonus points awarded for additional outcome/patient
experience
• Not available for claims
9
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
10. Measure Measure
Type
# of
Cases
Points Based
on
Performance
Total
Possible
Points (10 x
Weight)
Quality
Bonus
Points for
High
Priority
Quality
Bonus
Points for
EHR
Measure 1 Outcome
Measure using
CEHRT
20 4.1 10 0 (Required) 1
Measure 2 Process using
CEHRT
21 9.3 10 1
Measure 3 Process using
CEHRT
22 10 10 1
Measure 4 Process 50 10 10
Measure 5 High Priority-
Patient Safety
43 8.5 10 1
Measure 6
(Missing)
Cross-Cutting N/A 0 10
Acute
Composite
Admin. Claims 10 Not scored:
below minimum
sample size
Chronic
Composite
Admin. Claims 20 6.3 10
Total
Points
All
Measures
N/A 48.2 70 1 3
10
QUALITY
PERFORMANCE
SCORING
EXAMPLE
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
Key Take-Away: Know your measures. Include 1 Outcome & 1 Cross-Cutting
Measure. Consult CMS’ Core Set Measures.
11. QUALITY
PERFORMANCE
11
52.2 Total
Points
70 Possible
Points
74.6% Quality
Score
48.2 Points
1 Bonus Point
for high
priority
measure
3 bonus points
for CEHRT
Reporting
52.2 Total
Points
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
13. ACI BASE SCORE
13
Protect PHI
(Required)
CPOE
(E-Prescribing)
Patient Electronic
Access
(Patient Portal)
Coordination of Care
Through Patient
Engagement
Health Information
Exchange
Public Health/Clinical
Data Registry
Reporting (Required)
To receive full credit of the
base score, physicians will
need to report one unique
patient in each category
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
14. ACI BASE SCORE
PROPOSED
EXAMPLES
14
Protect PHI
•Security Analysis (Required)
Electronic Prescribing
•CPOE
Public Health and Clinical Data
Registry Reporting
•Immunization Registry Reporting
(Required)
•Syndromic Surveillance Reporting
(Optional)
•Electronic Case Reporting
(Optional)
•Public Health or Clinical Data
Registry Reporting (Optional)
Coordination of Care
Through Patient
Engagement
• View, Download, and
Transmit (VDT)*
• Secure Messaging*
• Patient-Generated Health
Data*
Health Information
Exchange
• Exchange Information with
Other Clinicians*
• Exchange Information with
Patients*
• Clinical Information
Reconciliation*
Patient Electronic Access
• Patient Access to PHI*
• Patient-Specific Education*
* = Proposed
Performance
Score
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
15. ACI
PERFORMANCE
SCORE
15
Patient Electronic
Access
Coordination of
Care Through
Patient Engagement
Health Information
Exchange
Physicians will be
proportionally scored
against their peers in
terms of patient
engagement with these
objectives
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
Key Take-Away: Get creative to encourage patients to utilize patient
portal.
16. CLINICAL PRACTICE IMPROVEMENT
ACTIVITIES: SUMMARY
90+ proposed activities categorized as “high” 20
point activities or “medium” 10 point categories
Full credit is achievement of 60 points
Patient-Centered Medical Home (PCMH)
guarantees full credit
APM participation receives a minimum of half
credit
16
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
17. CPIA
REPORTING
OPTIONS
17
Individual
Reporting
Attestation
QCDR
Qualified Registry
Electronic Health Record
Administrative claims (if technically
feasible, no submission required)
Group Reporting
Attestation
QCDR
Qualified Registry
Electronic Health Record
CMS Web Interface (Groups of 25+)
Administrative claims (if technically
feasible, no submission required)
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
18. CPIA SUBCATEGORIES
18
Expanded Practice
Access
Beneficiary
Engagement
Population Health
Management
Patient Safety and
Practice Assessment
Care Coordination
Participation in an
APM, including a
medical home model
These 6 subcategories
proposed in NPRM
Achieving Health
Equity
Emergency
Preparedness and
Response
Integrated
Behavioral &
Mental Health
These 3
subcategories
are required in
MACRA
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
19. CPIA EXAMPLESExpanded
Practice
Access
24/7 Access to
Care team
Telehealth
Patient Experience
used for QI
Projects
Population
Health
Management
Participation in
systemic
anticoagulation
program
Participation in a
QCDR
Monitor health
conditions
Care
Coordination
Participate in
Transforming
Clinical Practice
Initiative
Closing the referral
loop
Timely HIE with
patients &
providers
Beneficiary
Engagement
Collect & utilize
patient experience
data
Beneficiary
Training for self-
management
Patient portal
19
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
20 points!
Full Credit
= 60 points
10 points!
20. Patient Safety
& Assessment
Opioid Management
Use of Surgical
Checklists
STEPS Forward
Program
Achieving
Health Equity
Timely care for
Medicaid patients
Participate in State
Innovation Model
activities
Screen for SDOH
Emergency
Response
Participate in
Disaster Medical
Assistance teams
Participate in
domestic or
international
humanitarian work
Integrated
Behavioral &
Mental Health
Co-location of mental
health services in
clinical settings
Depression Screening
Substance abuse
prevention &
treatment
20
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
10 points!
20 points!
Full Credit
= 60 points
CPIA EXAMPLES
21. CPIA SCORING
SUMMARY
21
50 Total
CPIA
Points
60 Points
83% CPIA
Score
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
Participate in
TCPI
Telehealth
Use of
Surgical
Checklists
Patient Portal
50 Total
CPIA Points
83% x 15% weight for CPIA =
12.5 points towards MIPS
Composite Score
20 Point
Activity
10 Point
Activity
22. CPIA SPECIAL
SCORING
CONSIDERATIONS
22
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
• Non-patient facing eligible clinicians, small practices (15
or fewer professionals), rural practices, and clinicians in
geographic health professional shortage areas:
• 1st activity earns 50% of the 60 points
• 2nd activity earns 100% of the 60 points
• APM participation automatically earns 50% of the 60
points
• PCMH’s receive 60 points
23. RESOURCE UTILIZATION:
KEY CHANGES
Value Modifier
• 6 Measures; Total per capita costs for all
attributed beneficiaries
• Medicare spending per Beneficiary (MSPB)
• Total per capita cost measures for 4 condition-
specific groups (COPD, CHF, CAD, Diabetes)
• Attribution to group practice (TIN)
Proposed MIPS Resource Use Category
• 2 of the 6 VM measures; Total per capita costs
for all attributed beneficiaries
• Medicare spending per Beneficiary (MSPB)
• Removes total per capita cost for the 4
condition-specific groups
• Proposes up to 41 other episode-based
measures
• Attribution to group (TIN) or individual TIN or
NPI
23
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
24. RESOURCE UTILIZATION:
KEY CHANGES -
ATTRIBUTION
Value Modifier
• 2-step process for claims-based
measures
Proposed MIPS Resource Use
Category
• Expansion of primary care services
to align with MSSPs:
• Inclusion of CCM & TCM coding
• Exclusion of nursing visits
occurring in SNF
24
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
25. RESOURCE UTILIZATION:
KEY CHANGES - MSPB
Value Modifier
• MSPB measures care around a
hospitalization
• Adjusted for IP DRG & a separate
adjustment is applied to specialty
composition of group practice
• Minimum of 125 cases to be “reliably”
measured
Proposed MIPS Resource Use Category
• Individual cases measured the same
• 2 technical adjustments for MIPS:
• Modified individual case aggregation
• Removed specialty adjustment
• Two adjustments make MSPB more at the
smaller case volume
• 20 cases is the proposed threshold for
episode-groups
25
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
26. Resource
Use
Type of
Measure
# of
Cases
Performance Measure
Performance
Threshold
Points
Based
on
Decile
Total
Possible
Points
M1 MSPB 20 $15,000 $13,000 4.0 10
M2 Total Per
Capita
21 $12,000 $10,000 4.2 10
M3 Episode 1 22 $15,000 $18,000 5.8 10
M4 Episode 2 10 $11,000 $9,000 Below Case
Threshold
N/A
M5 Episode 3 0 N/A N/A No
attributed
cases
N/A
M6 Episode 4 45 $7,000 $10,000 8.3 10
Total 22.3 40 26
RESOURCE USE
SCORING
SAMPLE
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
27. RESOURCE USE
SCORING
Each measure
is converted to
decile points
(1-10)
(Only Includes
Case Volumes
>20)
Total Points
27
22.3 points
40 possible
points
55.8%
Resource
Use Score
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
28. Category Formerly
Known
As:
Year 1
Weight
Scoring Methodology
Quality PQRS 50% • Each measure 1-10 points compared to
historical benchmark
• 0 points for non-reported measure
• Bonus Points available
• Measures are averaged for total categorical
score
Advancing
Care
Information
Meaningful
Use
25% • Base score of 50% points achieved by
reporting at least one unique patient for each
measure
• Performance score of up to 80% points
• Public Health Reporting Bonus Point
• 100% points = Full Credit
CPIA N/A 15% • 10 Point “medium weight” activities & 20
Point “high-value” activities available
• 60 Points = Full Credit
Resource Use Value-
Modifier
10% • Similar Scoring to Quality Category
28
Quality
Advancing Care
Information
Clinical Practice
Improvement
Activities
Cost:
Resource
Utilization
MIPS COMPOSITE SCORE SUMMARY
29. TRANSFORMING CLINICAL
PRACTICE IMPROVEMENT GRANT
29
• CMS $685 million awarded to equip >140,000 clinicians with tools needed
to:
• Improve Care Quality
• Increase Patients’ access to information
• Assist in FFS>FFV Transformation
• Population Health IT Infrastructure
• Caravan Health
• Also known as “National Rural Accountable Care Consortium”
• Active in 43 states
• Uses “Lightbeam” Population health Solution
• Compass PTN
• Iowa Health Collaborative-Partnered with GHA
• Active in 6 states
• Uses “Telligen” Population Health Solution
30. TRANSFORMING
CLINICAL PRACTICE
IMPROVEMENT GRANT
30
Patient’s chief complaints
determines care
Systemically assess all
patient health needs
Care is determined by
today’s problem
Care is determined by
proactive care plan
Traditional
Approach
Transformed
Practice
Care varies by scheduled time
Care is standardized according
to evidence-based guidelines
Patients are responsible for
coordinating their own care
A TEAM of professionals
coordinate patient care
What?
How?
When?
Who?
Via Population
Health
Infrastructure