QUALITY PAYMENT PROGRAM Advancing Care Information Performance Category

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.

The Advancing Care Information, or ACI, MIPS performance category replaces the Medicare Meaningful Use program and focusses on key measures of health IT interoperability, promoting patient engagement and electronic information exchange. It uses many of the same measures clinicians been working on for years under Meaningful Use with the exception of the Computerized Provider Order Entry or CPOE measure and the Clinical Decision Support or CDS measure. Additionally, ACI eliminates the all or nothing thresholds for measurement, as well as most of the measure exclusions. In this new version of what was previously Meaningful Use whatever the numerator and denominator is for a measure, they translate into points. ACI also reduces the number of required public health registries that clinicians must be actively engaged with. The immunization registry measure is part of the performance score and being actively engaged with any additional public health registries earns participants bonus points. Along with bonus points, there are two scores which are calculated as part of the ACI category, the base score and the performance score.

The base score is worth 50 points of the total ACI performance category score. The Performance Score is worth up to 90 points. And participants can get up to an additional 15 points through earning bonus points. Those 3 point categories add up to create the ACI composite score. Although there are 155 points in total available, participants maximize the scoring potential of this performance category when they earn 100 points. Thus, ACI offers great flexibility, allowing clinicians to participate in a way that fits their scope of practice, yet still maximizing scoring potential. I will go into each scoring category in more detail. But first we need to discuss the use of Certified EHR Technology or CEHRT and how it relates to participating in the ACI performance Category.

Although all clinicians in the ACI performance category must use Certified EHR Technology or CEHRT to participate, the ACI measures you report on are dependent on which version of technology you use. There are 2 sets of ACI measures available to participants in 2017, the Advancing Care Information Objectives and Measures, which align with the Meaningful Use Stage 3 requirements, and the 2017 Advancing Care Information Transition Objectives and Measures, which align with the Meaningful Use Modified Stage 2 requirements. For those who have upgraded to the 2015 certified version of their EHR, they can choose to report using the regular ACI objectives and measures, the 2017 transition objectives and measures, or a combination of the 2 measure sets. For those who are still utilizing the 2014 certified version of their EHR, they will report either exclusively using the 2017 transition objectives and measures or can choose to report on a combination of the 2 measure sets, reporting on the regular objectives and measures for which their technology is capable.

Looking more closely at the Base Score component of the ACI performance category, this is the only place where there is still an all-or-nothing component, similar to the prior legacy Meaningful Use program. In order to receive the 50 points available, a clinician must meet ALL of the base score measure objectives. Failing to meet any of the base score measure objectives will result in a total ACI category score of zero. To meet base score measure objectives, the clinician needs to have a numerator of at least one for an applicable measure, or in the case of the security risk assessment, the clinician must be able to attest Yes to having completed it in 2017. So in terms of the electronic prescribing measure, when the clinician has submitted one prescription electronically, she has met the base score requirements. Do the same for the other base score measures, achieving a numerator of one or attesting Yes to the requirements of a yes/no measure, and the clinician has met the requirements for the Base ACI score and will be awarded the corresponding 50 points.

In calculating the Performance Score, clinicians can pick and choose which measures they would like to focus on, allowing program flexibility that did not exist under Meaningful Use. Here, whatever the measure’s numerator and denominator is, it converts into points that add up to a performance score of up to 90 points total or 10 points each. Here again the measures reported on are dependent on the version of EHR is in use, with the 2017 transition objectives having 2 less measures on which to report versus the regular objectives which align with Meaningful Use Stage 3. To compensate, two of the 2017 transition objectives, Provide Patient Access and Health Information Exchange are worth double, earning clinicians as many as 20 performance points each for those measures. When scoring a Yes/No measure, a clinician gets the full 10 points for attesting Yes to meeting the measure objective or zero points for not meeting the objective.

There are 2 ways that clinicians can earn bonus points in the ACI performance category. In terms of public health measures, the Immunization registry reporting measure is part of the Performance Score, earning an immunizing clinician 10 points for actively engaging with their applicable Public Health Agency to report Immunization data. Meeting the measure requirements for active engagement with any additional public health organizations earns a clinician up to an additional 5% in bonus points. Additional bonus points can also be earned by using Certified EHR Technology to report certain Improvement Activities. Here CMS has linked 2 of the MIPS performance categories, ACI and Improvement Activities. 18 of the 94 Improvement Activities can potentially earn a clinician up to 10% in ACI bonus points by utilizing CEHRT to implement the activity.

Looking at this first activity as an example, “Provide 24/7 access to eligible clinicians or groups who have real-time access to patient’s medical record”, if certified EHR technology is used to provide 24/7 access for clinicians to patient medical records, the implementation of this activity would earn the clinician ACI bonus points. There are 17 additional Improvement Activities which can also earn a clinician ACI bonus points if implemented using Certified EHR Technology.

Summarizing it all and bringing all of the ACI score components back into a rough scoring example, we have the base score worth either 0 or 50 points. Remember, if the base score requirements are not met, the clinician will receive an overall ACI composite score of zero as no ACI score can be achieved without meeting the base score requirements. Then we have the performance score, worth up to 90 points, which converts measure numerators and denominators into points using a decile system where a performance rate of 8% earns 1 point, a performance rate of 20% earns 2 points and so on up to 10 or 20 possible points depending on the measure. Clinicians can earn up to 15 bonus points for actively engaging in public health registries beyond the Immunization registry and for leveraging certified EHR technology in the implementation of certain Improvement Activity alignment. Those 3 scoring components then add up to the overall ACI composite score which is maximized when 100 total points are earned. And in a rough scoring example, if a MIPS eligible clinician receives the 50 point base score, earns a 40% performance score and no bonus points, she would earn a 90% ACI performance category score. When weighted by 25% as it is in 2017, this would contribute 22.5 points to the clinician’s overall MIPS Final Score. For most clinicians, meeting the legacy Meaningful Use program requirements and continuing those successful workflows typically translates into a high ACI score.

With some built in program flexibilities, a clinician’s ACI performance score may be reweighted to zero, meaning they do not have to participate in ACI, and shifts that weight to the Quality performance category. The following provider types qualify for automatic ACI performance category reweighting to zero percent: Hospital-based MIPS Clinicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists and Clinicians who lack face-to-face interactions with patients. These ECs can still choose to override this automatic reweighing and report on ACI if they would like, and if reported, CMS will score their performance accordingly. A clinician can also apply to have their performance category score weighted to zero and have that weight shifted to the Quality performance category for the following reasons: Insufficient internet connectivity, Extreme and uncontrollable circumstances or Lack of control over the availability of CEHRT.

In summary, the Advancing Care Information MIPS performance category replaces the Medicare Meaningful Use program. The scoring for this category, which is the primary difference from the prior legacy program, is split into 2 main parts, the Base Score and the Performance Score. There are 2 sets of measures to choose from depending on the version of EHR technology in use. Bonus points are available for additional Public Health reporting and for using Certified EHR Technology to implement certain Improvement Activities. There are flexibilities built into this performance category which allows for category reweighting based certain conditions or types of providers. And achieving the previous Meaningful Use requirements typically translates into a high ACI score