maximizing performance in mips! - medical advantage group · 8/14/2017 · macra jumpstart –...

Maximizing Performance in MIPS!

Beth HickersonLead Quality Improvement Advisor

August 14, 2017

Value Driven. Health Care. Solutions.

MACRA Jumpstart – Maximizing Performance in MIPS!

2Value Driven. Health Care. Solutions.

At the close of our presentation you should have a better idea of how to improve accuracy and performance in your reporting and documentation for MIPS. We will also share free CMS Resources for MIPS support:

– QPP Resource Center– www.qppresourcecenter.com

– Medical Advantage Group’s MACRA Jumpstart– www.medicaladvantagegroup.com/macra

jumpstart/– [email protected]

http://www.qppresourcecenter.com/

http://www.medicaladvantagegroup.com/macrajumpstart/

mailto:[email protected]

Need to Catch Up?


If today is your first webinar with us and you need to catch up, visit our MACRA Jumpstart Website: – www.medicaladvantagegroup.com

/macrajumpstart/

We have a library of past MACRA Jumpstart Webinars, and many other resources to help you get off to a successful start:– June 21 – Using Free CMS

Resources for MIPS Success– July 12 – Preparing Your Small

Practice for MIPS Success


REVIEW OF MIPS SCORING

Quality

Quality Overview

RequirementsReport 6 measuresInclude at least 1 outcome or high priority measureChoose from 291 generally approved MIPS measures


Scoring60 possible category points3-10 points per measure based on performance against a benchmark Up to 12 bonus points available

60Points

Understanding Benchmarks

Benchmark – standard based on historical data2017 Quality benchmarks set from 2015 PQRS data– Mean/Average determined– Performance scores distributed along a decile range

Download “2017 Quality Benchmarks" at https://qpp.cms.gov/about/resource-library


Measure Name Submission Method Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10

Pneumonia Vaccination Status for Older Adults Claims 39.78 -

51.3251.33 -61.67

61.68 -70.47

70.48 -77.77

77.78 -84.49

84.50 -91.99

92.00 -99.06 >= 99.07

Pneumonia Vaccination Status for Older Adults EHR 14.13 -

23.2523.26 -33.02

33.03 -43.58

43.59 -53.96

53.97 -63.60

63.61 -74.54

74.55 -85.52 >= 85.53

Pneumonia Vaccination Status for Older Adults Registry/QCDR 12.24 -

24.0224.03 -36.34

36.35 -48.51

48.52 -58.95

58.96 -68.05

68.06 -77.77

77.78 -90.19 >= 90.20

https://qpp.cms.gov/about/resource-library

Quality Category Bonus Points

Additional High-priority or Outcome measures – High-priority = 1 point per measure– Outcome = 2 points per measure– Up to 6 points maximum

“End-to-End” Electronic reporting – From point of service through to CMS– EHR– Registry or QCDR if data extracted and submitted to

CMS electronically– 1 point per measure, up to 6 points maximum


Quality Category Score


Each measure

earns 3-10 points

End-to-End

bonus points

High-priority

and Outcome

bonus points

TOTAL POINTS EARNED

REVIEW OF MIPS SCORING

Advancing Care Information

ACI Overview


– Security risk analysis– e-Prescribing– Provide patient access– Send summary of care

– 5 percent per measure for public health/clinical data registry reporting

– 10 percent for improvement activity alignment

– Submit 7 measures for 90 points for performance credit

Required base score (50)

Performance score (up to 90)

Bonus score (up to 15)

50 90 15

2017 Transition Objectives and Measures

Core (Required)50 Points1. Security Risk Analysis2. e-Prescribing3. Provide Patient Access4. Health Information

Exchange

Performance (Optional)Up to 90 Points1. Provide Patient Access*2. Health Information*

Exchange3. View, Download, or

Transmit (VDT)4. Patient-Specific Education5. Secure Messaging6. Medication Reconciliation7. Immunization Registry

Reporting


*Performance points doubled on these measures

Performance Measure Scoring


Performance Rates for Each Measure

1-10% = 111-20% = 221-30% = 331-40% = 441-50% = 5

51-60% = 661-70% = 771-80% = 881-90% = 9

91-100% = 10

Advancing Care Information Bonus Points

Public Health or Clinical Data Registry Reporting– 5 points – Includes Syndromic Surveillance, Cancer Registry,

QCDRs, etc.

CEHRT-related Improvement Activity– 10 points– See list under Appendix B of “Advancing Care

Information Performance Category Fact Sheet” at https://qpp.cms.gov/docs/QPP_ACI_Fact_Sheet.pdf


https://qpp.cms.gov/docs/QPP_ACI_Fact_Sheet.pdf

Advancing Care Information Category Score


Base Points

(50)

Performance Points

(up to 90)

Bonus Points

(up to 15)

TOTAL POINTS EARNED

STRATEGY #1

Maximize Bonus Points

Quality Category Bonus Points

Check with your EHR or registry to see if you qualify for “end-to-end” electronic reporting pointsReport on additional high-priority and outcome points– Report more than 6 measures overall– Report as many measures as possible to achieve maximum 6

points– Report even if performance is low – Additional measures must have at least 20 patients in the

denominator and 1 patient in the numerator to qualify


Advancing Care Information Bonus Points

Research QCDRs and/or Specialized Registries applicable for your specialty– Consider cost and time required to meet this

requirementReview the CEHRT-related Improvement Activities for activities you are already doing or could easily do– Start activity by October 2nd for full 90 day period– See Appendix B of “Advancing Care Information

Performance Category Fact Sheet” at https://qpp.cms.gov/docs/QPP_ACI_Fact_Sheet.pdf

– Download “MIPS Data Validation Criteria” at https://qpp.cms.gov/about/resource-library


https://qpp.cms.gov/docs/QPP_ACI_Fact_Sheet.pdf

https://qpp.cms.gov/about/resource-library

STRATEGY #2

Understand Measure Specifications

Review Your Measure Specifications

Measure specs include – Numerator and denominator details– Exclusion and Exception criteria – Measure Rationale (Quality)– Additional Information (ACI)Quality Measure Specs for Claims and Registryhttps://qpp.cms.gov/docs/QPP_quality_measure_specifications.zip

eCQM Measure Specshttps://ecqi.healthit.gov/eligible-professional-eligible-clinician-ecqms

ACI Measure Specshttps://qpp.cms.gov/docs/QPP_Advancing_Care_Information_Measure_Specifications.zip

https://qpp.cms.gov/docs/QPP_quality_measure_specifications.zip

https://ecqi.healthit.gov/eligible-professional-eligible-clinician-ecqms

https://qpp.cms.gov/docs/QPP_Advancing_Care_Information_Measure_Specifications.zip

Claims and Registry Specs


eCQM Specs


Note: Scroll down and click on the .html file under Specifications for full details

Advancing Care Information Specs


STRATEGY #3

Align Documentation Workflows

Defining “Align Documentation Workflows”

Entering data in the specific EHR field where it is tracked for your Quality and ACI measuresCommon data tracking areas:– Modules (Vitals, Medication, Immunization, Family

History, Social History)– Health Maintenance Record– Lab results– Smart templates in visit notesMeasures will always track via discrete data fields, never text fields or scanned documents

Documentation Red Flags

Performance rates don’t make sensePerformance rates of 0% or 100%Performance rates vary widely from benchmarksPerformance rates vary significantly between practice providers


Steps for Aligning Workflows in EHR

1. Request a copy of updated workflow instructions from your EHR– May be called “whitepapers”– May be found via support link in EHR– May be updated annually

2. Review the workflow instructions with your most knowledgeable provider AND clinical staff member– Do instructions match real-life habits?

3. Train staff and providers on new workflows– If many to correct, train one or two at a time


Steps for Aligning Workflows in EHR (cont.)

4. Print baseline Quality and ACI reports– Take note of the data that new workflows were

implemented– You should see improvement within 1-3 months

5. Share measure data with staff and providers to highlight errors and improvement– They can’t argue with data!

6. Track quality measures on a monthly basis– Notify your EHR vendor immediately if you notice

inconsistencies


Aligning Workflows with a Registry

Understand how your data is mapped electronically– Measures may be tracked differently in your registry than

in your EHRReview registry reports monthly – If reporting MIPS via registry, your registry reports trump

your EHR reportsBe prepared for mapping errors when your EHR is updated


STRATEGY #4

Alter Clinical Workflows

Tips for Improving Performance

Involve your staff– Informal or formalDon’t reinvent the wheel– Look for “bright spots” and identify repeatable habits– Share ideas with a peer practice– Search the web for improvement ideasTest change before implementation– Avoid unnecessary confusion– Demonstrate success to create buy-inFocus on highest impact measures– Check benchmark deciles


Tips for Improving Performance (cont.)

Focus on highest impact measures– Topped out?– Check benchmark deciles


Measure_Name Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10 Topped Out

Pneumonia Vaccination Status for Older Adults

12.24 -24.02

24.03 -36.34

36.35 -48.51

48.52 -58.95

58.96 -68.05

68.06 -77.77

77.78 -90.19 >= 90.20 No

Diabetes: Eye Exam69.39 -89.68

89.69 -95.95

95.96 -98.72

98.73 -99.99 -- -- -- 100 Yes

Questions?


Next Webinar – Sept. 6


Visit Medical Advantage Group’s MACRA Jumpstart Page:– www.medicaladvantagegroup.com/mac

rajumpstart/

Register for our Sept. 6 webinar: – MACRA Jumpstart: MIPS Quality

Category 101 – This will be a primer on reporting quality

measures

View our other upcoming webinars:– Oct. 12 – MIPS Advancing Care

Information 101– Nov. 9 – QPP Final Rule for 2018


Beth [email protected]


maximizing performance in mips! - medical advantage group · 8/14/2017 · macra jumpstart –...

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