QUALITY PAYMENT PROGRAM Quality Performance Category VIDEO

The Merit-based Incentive Payment System or MIPS is one of two participation paths of the new Quality Payment Program or QPP. The Quality Payment Program, contained within MACRA, the Medicare Access and CHIP Reauthorization Act of 2015, is part of a broader effort by CMS, the Centers for Medicare and Medicaid Services, to shift from a volume based payment system, to one which rewards clinicians demonstrating high quality and value by penalizing those who are not. The QPP replaces and consolidates several legacy Medicare programs, combining them into a single program with flexibility that allows participants to choose the activities and measures which are most meaningful. MIPS consolidates the Physician Quality Reporting System or PQRS, now the Quality performance category of MIPS, the Value-modifier program, now the Cost performance category, the Medicare EHR Incentive Program, now the Advancing Care Information performance category and adds a new fourth performance category called Improvement Activities.

The performance of MIPS participants, referred to as Eligible Clinicians or ECs, is measured across the four weighted performance categories on a 100 point scale, called the Final Score, which is then compared against an annual performance threshold, with Medicare Part B reimbursement rates adjusted based on program performance. In the first Transition Year of the program, to give participants additional time to prepare, clinicians will not be assessed using the Cost performance category, thus only 3 of the 4 MIPS performance categories will be used in 2017. In this initial year of the program, the Quality performance category is worth 60% of the Final Score, the Improvement Activities performance category is worth 15% of the Final Score, and the Advancing Care Information performance category is worth 25% of the Final Score.

In the Quality performance category, worth 60% of the Final Score in 2017, clinicians choose between a current list of 271 quality measures similar to those previously used in the legacy PQRS program. Reporting on a minimum of 6 measures for at least 90 days of the calendar year is required for full participation in 2017. One of the selected measures must be an Outcome measure or if an Outcome measure is not available for the clinician, then a high-priority measure must be chosen instead. A High-priority measure is defined as an outcome measure, appropriate use measure, patient experience measure, patient safety measure, efficiency measure or care coordination measure. There are different program requirements for groups reporting via the CMS Web Interface or those participating in MIPS APMs. To assist in measure selection, clinicians may also select and report on a defined specialty-specific set of measures. Additionally, groups reporting that have 16 or more clinicians and a sufficient number of cases are automatically assessed on an additional population measure, the 30-day All-cause Hospital Readmission measure. Information on quality measures, including their required specifications, can be found at QPP.CMS.GOV.

We’ll next discuss the scoring methodology for the Quality performance category of MIPS.

For each of the 6 measures reported, clinicians can receive between 3 and 10 points for performance on that measure as compared against that measure’s benchmark. We’ll explore benchmarks more in a moment, as understanding how the benchmarks work is a vital component to scoring well in MIPS. As long as the denominator for the measure is greater than zero, the clinician will receive at least 3 points for that measure, with more points earned with better measure performance. To score above 3 points on a measure, the EC must meet minimum case volume criteria which may be easier to achieve by lengthening the participant’s reporting period beyond the minimum 90 days required for full participation. Failure to submit performance data for any of the required 6 measures will result in 0 points for that measure. Additionally, bonus points are available for clinicians who report additional Outcome, High-priority or patient experience measures beyond the required 6 quality measures and for submitting quality data to CMS electronically.

Understanding benchmarks is vital to successful MIPS scoring. If a measure CAN be reliably scored against a benchmark, then the clinician can receive between 3 and 10 points for that measure depending on performance. To be scored against a benchmark, 3 conditions must be met. First, the benchmark must exist. More to come on this condition in a moment. Second, there must be sufficient case volume for the measure. Sufficient case volume means the measure must have at least 20 patients which it applies to in the reporting period for most measures and at least 200 patients for the readmission measure which is automatically applied to groups of 16 or more clinicians who choose the group reporting option. Finally, data completeness criteria must also be met in order to be reliably scored against a benchmark. For 2017, the data completeness threshold is set a 50%. This means that at least 50% of the patients to which the measure applies must be measured against the measure specifications. If a measure cannot be reliably scored due to failing any of these 3 criteria, the clinician can only receive 3 points for that measure, regardless of actual measure performance. Again, clinicians may find it easier to meet the sufficient case volume criteria for a quality measure by extending the reporting period beyond the minimum 90 day requirement for full participation.

As was discussed in the Quality Payment Program overview video, there are several different ways that participants can submit their Quality data to CMS. For this performance category, ECs can submit data using their EHR vendor, they may enlist the help of a data registry to capture and report quality data, they may submit quality data directly to CMS via the claims process, or groups of 25 or more clinicians may submit data using the CMS Web Interface. Benchmarks are established separately for each data submission method and there is often tremendous variation in benchmarks by each method. Quality measure performance which earns an EC high points via one submission method may score significantly lower by utilizing a different submission method. Thus, it is not only important to carefully select quality measures which accurately represent the provider’s scope of practice and contain sufficient data, but it is perhaps equally important to utilize an available reporting mechanism which awards the clinician the highest possible quality score based on measure performance. Although benchmarks are established separately for each data submission method, the benchmarks are the same whether reporting as an individual or a group of clinicians. Not all of the 271 quality measures currently have established benchmarks. If a chosen quality measure does not have an established benchmark, the maximum points available for that measure, regardless of actual performance by the clinician or group, is 3 points. CMS will attempt to establish benchmarks for those measures currently missing them utilizing the data they receive in 2017. To establish a quality measure benchmark, CMS must receive data on that measure from at least 20 submitters which each meet or exceed the minimum case volume standard, data completeness criteria and has performance on the measure that is greater than zero. If a benchmark cannot be established, submitters will receive 3 points for that measure.

There are 2 ways that participants can receive bonus points in the Quality performance category of MIPS. First, clinicians can receive 2 bonus points for each additional outcome and patient experience measure submitted beyond the required 6 measures for full participation. Additionally, clinicians may receive 1 bonus point for each additional high-priority measure submitted. Finally, for submitting data to CMS utilizing a method deemed end-to-end electronic reporting, which looking at the submission options is all except Claims based reporting, clinicians will receive 1 bonus point for each electronically submitted measure. Bonus points are capped at an additional 20% of the overall Quality category score, which is up to 10% for additional measure reporting and up to 10% for electronic measure submission.

A clinician’s or group’s total quality performance category score is derived by taking the points earned on the required 6 quality measures plus any bonus points earned for additional measure reporting or submitting data electronically divided by the maximum number of points available. The maximum number of points equals the number of required measures times 10. We’ll look at the variations in the maximum number of points available next.

The total number of points available varies by submission method, and if group reporting, by the addition of the hospital readmission measure if applicable to that group. The measures and scoring via the CMS Web Interface varies from the other submission methods. Instead of choosing 6 measures, when groups of 25 or more clinicians utilize the CMS Web Interface reporting, they are assessed against a defined set of 15 measures, including the hospital readmission measure if applicable, and are score against 12 of them. Thus, the maximum number of points via the CMS Web Interface submission method is 120 or 110 depending on the applicability of the hospital readmission measure. For all other submission methods, the maximum number of points is either 70 for those also being assessed against the hospital readmission measure or 60 points for those who the readmission measure does not apply.

In summary, the Quality performance category of MIPS is worth 60% of the Final Score in 2017. There are 271 measures to choose from including Specialty measure sets to ease the burden of measure selection. To participate fully in MIPS, clinicians must report sufficient data on a minimum of 6 quality measures. Careful measure selection is vital to program success. Because different benchmarks are established for each data reporting method, choosing how to submit data to CMS can have a profound effect on the Quality category score. Each measure earns between 3 and 10 points as long as benchmarks have been established for the measure. If benchmarks don’t exist, CMS will attempt to calculate them using 2017 data. If not possible, a maximum of 3 points can be earned for the measure regardless of actual measure performance. Bonus points can be earned by reporting additional quality measures and for reporting data via an end-to-end electronic submission method.