MIPS 2021: Proposed Rule Key Takeaways

The Centers for Medicare and Medicaid Services (CMS) has released the Quality Payment Program (QPP) proposed rule for the 2021 performance year. To accommodate for the challenges posed by COVID-19, CMS is not proposing many significant changes to the Merit-based Incentive Payment System (MIPS) for 2021. Here are the highlights of the proposed rule for next year. For information on the current performance year, see our MIPS 2020 page.

MIPS Value Pathways

Introduction of MIPS Value Pathways (MVPs), the new framework originally set to begin implementation in the 2021 performance year, will be postponed. CMS will continue to work on engaging stakeholders and developing the framework’s guiding principles.

APM Performance Pathway

CMS has proposed an APM Performance Pathway (APP), complementary to MVPs. This option would be available to MIPS APM participants only and would be composed of a fixed set of measures for each performance category. The APP performance measures would also satisfy reporting requirements for the Medicare Shared Savings Program quality scoring.

Performance Category Weights

In 2021, the proposed Quality performance category weight will be reduced from 45 percent to 40 percent. The Cost category weight will increase from 15 percent to 20 percent.

MIPS Performance Category Weights

Performance Threshold

For the 2021 performance period, CMS proposes to increase the performance threshold (maximum number of points needed to avoid a negative payment adjustment) from 45 to 50 points. There is no change to the exceptional performance threshold (number of points needed for a positive payment adjustment) of 85 points.

MIPS Performance Thresholds

Performance Categories

Quality Category

CMS proposes to use performance period benchmarks, rather than historical, to score quality measures. Previously, the benchmarking baseline period was the 12-month calendar year two years prior to the MIPS performance year. CMS hopes to ensure accurate and reliable data due to possible gaps in baseline data due to COVID-19. Therefore, in 2021, the agency proposes to use benchmarks from the 2021 performance period instead of the 2019 calendar year.

CMS also proposes to end the CMS Web Interface as a quality reporting option for ACOs and registered groups, virtual groups, or other APM Entities beginning with the 2021 performance period.

Improvement Activities Category

Minimal updates would be made to the Improvement Activities inventory. A process would also be established for agency-nominated improvement activities.

In 2021, there are no proposed changes to the requirement that at least 50% of the clinicians in the group or virtual group must perform the same activity during any continuous 90-day period in the performance year.

Cost Category

CMS proposes to update existing measure specifications to include telehealth services that are directly applicable to existing episode-based cost measures and the TPCC measure.

COVID-19 Flexibility Scoring Proposals

For the 2020 performance period only, the maximum number of bonus points available for the complex patient bonus would be 10, to account for the additional complexity of treating patients during the COVID-19 public health emergency.

You can view the full 2021 QPP Proposed Rule fact sheet here.

MIPS and SurveyVitals

SurveyVitals can help you satisfy certain MIPS requirements. Learn more on our MIPS page, sign up for a demo, or chat with us using the blue chat icon below.

August 6th, 2020 Categories: featured, MIPS Information

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MIPS 2021: MVPs and QCDR Changes Coming

MIPS Final Rule 2020

Last week, CMS released the final rule for the changes to the Merit-Based Incentive Payment System (MIPS). While there are only minor changes to the program in 2020, bigger changes are expected in 2021. Here are two of the big takeaways from the final rule.

MIPS Value Pathways (MVPs)

CMS intends to move toward what they say would be a more streamlined MIPS program. To fulfill upon this vision, the agency intends to reduce reported complexities with data submission and confusion surrounding measure selection with a new framework they are calling MIPS Value Pathways (MVPs).

In the MVP framework, CMS intends to work with stakeholders to create sets of measure options that they say would be more relevant to clinician scope of practice and meaningful to patient care. MIPS-eligible clinicians would no longer choose their measures from a single inventory, but would instead fulfill pre-defined measures and activities connected to a specialty or condition.

At this time, CMS has not determined whether participation in MVPs in 2021 would be optional or mandatory.

Many aspects of the MVP framework are still unclear, and we will be following and providing updates as they are released by CMS. Subscribe to our MIPS newsletter to keep up to date on the MVP discussion.

Qualified Clinical Data Registries (QCDR)

In the current QPP landscape, QCDRs are not required to support multiple MIPS performance categories. However, beginning in performance year 2021, QCDRs will be required to submit data for the Quality, Improvement Activities, and Promoting Interoperability categories for the entire performance year and applicable submission period.

CMS is looking to achieve alignment of similar measures across QCDRs, with an emphasis on outcome measures. Starting in 2021, this would require full measure development and testing at the clinician level prior to the time of self-nomination. Additionally, CMS would implement a set of formalized guidelines for QCDR measure rejections.

You can read more about these proposed changes in the Quality Payment Program final rule.

November 6th, 2019 Categories: featured, MIPS Information

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MIPS 2020: Key Takeaways

MIPS 2020 Final Rule

Last week, CMS released the final rule for the changes to the Merit-Based Incentive Payment System (MIPS) in 2020. Changes to the program next year are minimal, but are still important to note as you head into performance year 4.

Performance Category Weights

There will be no change to the performance category weights in MIPS performance year 2020.

MIPS Performance Categories

Payment Adjustment

For the 2020 performance period, the performance threshold (maximum number of points needed to avoid a negative payment adjustment) will increase from 30 to 45 points. The additional performance threshold for exceptional performance will increase from 75 points to 85.

The maximum positive payment adjustment for performance year 2020 will be increased to 9%, plus additional adjustments for exceptional performance. The maximum negative payment adjustment will be -9%.

Quality Performance Category

Data completeness for performance year 2020 will increase from 60% to 70%. This means you must report on at least 70% of your total patients who meet the measure’s denominator criteria in order to receive maximum points for the measure.

Improvement Activities Category

The Improvement Activities inventory has been updated for MIPS performance year 2020.

MIPS Year 4 Changes to Improvement Activities
Added
  • IA_BE_25: Drug Cost Transparency
  • IA_CC_18: Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes
Modified
  • IA_PSPA_28: Completion of an Accredited Safety or Quality Improvement Program
  • IA_PM_2: Anticoagulant Management Improvements
  • IA_EPA_4: Additional improvements in access as a result of QIN/QIO TA
  • IA_PSPA_19: Implementation of formal quality improvement methods, practice changes, or other practice improvement processes
  • IA_BE_7: Participation in a QCDR, that promotes use of patient engagement tools
  • IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements
  • IA_BMH_10: Completion of Collaborative Care Management Training Program
Removed
  • IA_PM_1: Participation in Systematic Anticoagulation Program
  • IA_CC_3: Implementation of additional activity as a result of TA for improving care coordination
  • IA_PSPA_14: Participation in Quality Improvement Initiatives
  • IA_PSPA_5: Annual Registration in the Prescription Drug Monitoring Program
  • IA_PSPA_24: Initiate CDC Training on Antibiotic Stewardship
  • IA_BMH_3: Unhealthy alcohol use
  • IA_BE_11: Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan
  • IA_BE_2: Use of QCDR to support clinical decision making
  • IA_BE_9: Use of QCDR patient experience data to inform and advance improvements in beneficiary
  • IA_BE_10: Participation in a QCDR, that promotes implementation of patient self-action plans
  • IA_CC_6: Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination
  • IA_AHE_4: Leveraging a QCDR for use of standard questionnaires
  • IA_AHE_2: Leveraging a QCDR to standardize processes for screening
  • IA_PM_10: Use of QCDR data for quality improvement such as comparative analysis reports across patient populations
  • IA_CC_4: TCPI Participation

Previously, a group or virtual group could attest to an improvement activity if at least one clinician in the group participated in the activity. In 2020, in order for a group or virtual group to attest to an improvement activity, at least 50% of the clinicians in the group or virtual group must perform the same activity during any continuous 90-day period in the performance year.

CMS has also made a technical correction to the definition of ‘Rural Area’ that will not change how rural clinicians are identified.

Also modified are the requirements for patient-centered medical home (PCMH) designation. CMS has removed specific examples of entity names of accreditation organizations in order to remove barriers to designation.

Promoting Interoperability

Currently, hospital-based clinicians who choose to report as a group or virtual group are eligible for reweighting when 100% of the MIPS-eligible clinicians in the group meet the definition of a hospital-based MIPS eligible clinician. In the next performance year, these clinicians are eligible for reweighting when more than 75% of the NPIs in the group or virtual group meet the definition of a hospital-based MIPS eligible clinician.

MIPS Performance Year 2021

Although there are no major changes to the program for 2020, bigger changes are expected in performance year 2021. Subscribe to our MIPS newsletter to stay up to date on these future changes.

November 5th, 2019 Categories: featured, MIPS Information

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Provider Spotlight: Clint Allred, CRNA, Anesthesia Associates of Boise

Provider Spotlight: Clint Allred

Clint Allred, a full-time CRNA for Anesthesia Associates of Boise, was the grand prize winner of our recent Patient Experience Week giveaway. He is performing in the top 25% of anesthesia providers nationally. We asked Clint about his best practices for providing exceptional patient care, and we’re excited to share his responses.

Clint completed his nursing education at Weber State University in 2006, and then attended the University of Tennessee for CRNA training. He has been practicing in Boise since 2011.

What best practices do you and the staff you work with follow that you attribute to your positive scores?

Clint Allred: There is a huge push in our profession to unite with our surgeon colleagues and work toward “enhanced recovery after surgery ” protocols. We have known that there are a lot of different ways to manage the anesthetic of a patient, and each patient requires a different anesthetic. The downside to this is the fact that everyone does something different so the continuity of care is sometimes lacking.

To correct this discrepancy, we created a quality committee within our group. This committee was tasked with reviewing literature along with some of the bigger medical institutes, and then sitting down with anesthesia providers from within our group and developing some protocols for the surgeries that we provide routinely. This initiative at least put all of us on the same page to start with. These protocols deal not only with the patient during surgery, but also some interventions before surgery to improve their outcomes. Since installing these protocols, it has been incredible to see the patient, surgeon, and nurse satisfaction elevate. Every anesthetic still needs to be tailored just right, but this has really helped us be proactive in our decision prep.

What is one example of how you improved your relationship with your patients and/or the care you provide?

Clint Allred: It has amazed me how a little bit of effort goes a long way in ensuring comfort for our patients. It can be something as simple as a warm blanket in the cold metal OR, or talking with the patient on their level trying to take time to explain things.

One thing that we have instituted is in our pediatric population. The inhalational anesthetics that we use have a pungent smell. Kids really hate inhaling that odorous gas. So, we bought a bunch of Lip Smacker chapsticks and then bring the mask to the kids and let them pick out a flavor. They paint the inside of the mask with the flavor they selected and it negates that bad smell when the mask is on their face. Little things like these efforts don’t really take a cumbersome amount of time or energy. They just require a little effort and can really improve the relationship with patients.

What is one thing you avoid doing in order to provide a better experience for your patients?

Clint Allred: The biggest thing I have had to make a conscious effort to try and avoid is just going through the motions with my patients preoperatively. I have always taken pride in the quality of anesthesia care that I provide, but I realized when my son had surgery, that I really needed to change my approach to patients before they even have anesthesia. The day of surgery for patients is an overwhelming experience. Even before you get to the surgery and recovery phase, so much is thrown at them. I found that because administering anesthesia is a routine part of my life, I was just doing the bare minimum to educate and put my patients at ease. We would then whisk them away and go provide anesthesia. My experience taught me that taking an extra five minutes to sit down and talk with the patients about what they were going to experience, both for them and their family members, went a long way to easing their anxiety.

How do you best use your SurveyVitals data for your own personal improvement?

Clint Allred: SurveyVitals definitely serves as a reminder to keep those goals and changes, instituted in my own personal practice, in the forefront of my mind daily. Obviously, I won’t make everyone happy all the time. I used to just shrug my shoulders and act like it didn’t matter. However, what I did find is that when I changed my attitudes and practice – all of a sudden the SurveyVitals data meant something to me. It is a way to drive and improve my practice. I still won’t make every patient happy all the time, but I can take pride in my work and raise the bar for my patients.

August 6th, 2019 Categories: Anesthesia, Best Practices, Client Spotlight, featured, Patient Experience

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CMS Proposes New Measure Specialty Sets, MIPS Value Pathways

What are MIPS value pathways


The final rule for MIPS 2020 outlines the changes to the MIPS program coming in 2021. Read more here.

This week, CMS released the proposed rule for Year 4 of the Quality Payment Program (QPP). Many of the Year 3 requirements will be maintained going into the 2020 performance year; we highlighted the proposed changes in our blog post here. However, there are bigger proposed changes in store for Year 5 of the QPP starting in 2021.

In the latest release, CMS expressed an intention to move toward what they say would be a more streamlined MIPS program. To fulfill upon this vision, the agency is aiming to reduce reported complexities with data submission and confusion surrounding measure selection with a new framework they are calling MIPS Value Pathways (MVPs).

Check out key takeaways below from the proposed rule on MVPs and what CMS has put forth as a very loose framework for the future of the program.

CMS is soliciting public comment on the proposed rule until September 27, 2019 at 5 PM EST.

MIPS Value Pathways defined

The MVP framework would create sets of measure options that CMS says would be more relevant to clinician scope of practice and meaningful to patient care by connecting MIPS measures across the four performance categories specific to specialty or condition. It would also incorporate a set of administrative claims-based quality measures that focus on population health and provide data and feedback to clinicians. CMS says it intends to use the current MIPS specialty measure sets as a base framework for developing these new MVPs. The agency also indicated they will seek to enhance information provided to patients, with possible exploration of new forms of public reporting.

How does the MVP framework change MIPS?

If implemented, all MIPS-eligible clinicians would no longer choose their measures from a single inventory, but would instead fulfill measures and activities connected to a specialty or condition as a part of an MVP. This means the MIPS program would no longer require the same number of measures or activities for all clinicians.

CMS anticipates that an MVP would use a single benchmark for each measure, and all clinicians and groups in the MVP would be compared against the same standard. It is proposed that scoring policies would be evaluated to ensure scoring across MVPs is equitable, so that clinicians reporting a specific MVP are not unfairly advantaged. The agency says this would eliminate the need for special scoring policies and bonuses to incent selection of high priority or outcome measures, as clinicians would be required to report all measures in the MVP.

Additionally, MVPs will focus on bundling quality measures with existing, related cost measures and improvement activities as CMS sees feasible.

How will MIPS data collection be impacted by MVPs?

It is unclear at this time exactly how clinicians and groups will be expected to report data to satisfy measures under the new MVP framework. CMS says that the current MIPS performance measure collection types will continue to be used to the “extent possible,” creating some uneasiness for clinicians and industry leaders who have invested time and resources in their current reporting mechanisms. CMS is soliciting feedback around data submission mechanisms, particularly QCDRs and their role in the program. The agency maintains that a driving force behind the proposed changes is that the flexibility of the program in years 1-3 resulted in multiple benchmarks for each measure and specialty, hindering the ability of CMS to make meaningful comparisons.

Agency emphasizes patient experience and patient reported outcomes

The proposed rule also emphasized an increased focus on patient reported measures, including patient experience, satisfaction and outcomes in their performance measurement. The agency anticipates the MVP framework will provide more meaningful information to patients, which will enable them to make decisions about their care and achieve better outcomes.

CMS Example of Possible MIPS Value Pathway
MVP Example Quality Measures Cost Measures Improvement Activities Promoting Ineroperability
Preventive Health
  • Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (Quality ID: 226)
  • Osteoarthritis: Function and Pain Assessment (Quality ID: 109) Adult Immunization Status, proposed (Quality ID: TBD)
  • Controlling High Blood Pressure (Quality ID: 236)
  • PLUS: population health administrative claims quality measures (e.g., allcause hospital readmission)
  • Total Per Capita Cost (TPCC_1)
  • Medicare Spending Per Beneficiary (MSPB_1)
  • Chronic Care and Preventive Care for Empaneled Patients (IA_PM_13)
  • Engage patients and families to guide improvement in the system of care (IA_BE_14)
  • Collection and use of patient experience and satisfaction data on access (IA_EPA_3)
  • All measures in Promoting Interoperability***

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August 1st, 2019 Categories: featured, MIPS Information, Patient Experience

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CMS Releases 2020 MIPS Proposed Rule


CMS has released the final rule for MIPS 2020. Read the key takeaways here.

If you’re participating in MIPS, you’ll need to know about the changes to the program in 2020. This week, CMS released the Quality Payment Program proposed rule for the next performance year. While their goal is to maintain many of the requirements from the 2019 performance year, there are some updates to the MIPS track. Here are the highlights of the proposed changes.

Quality and Cost performance category weights

In 2020, the Quality performance category weight will be reduced from 45 percent to 40 percent. The Cost category weight will increase from 15 percent to 20 percent.

Payment adjustment

The maximum negative payment adjustment will increase from -7% to -9% in 2020. Positive payment adjustments (not including exceptional performance) will increase from 7% to up to 9%.

Performance threshold

The performance threshold–the minimum number of points to avoid a negative payment adjustment–will increase from 30 points in 2019 to 45 points in 2020. The exceptional performance threshold, which determines additional positive payment adjustments, will increase to 80 points in 2020.

A full breakdown of proposed MIPS changes can be found in the table below. CMS is accepting feedback on the proposed rule at regulations.gov through September 27, 2019 with the file code CMS-1715-P.

CMS has also proposed larger changes to the program starting in 2021. Click here to read our summary of their new proposed framework.

For more information on the current MIPS performance year and how SurveyVitals can help you fulfill your requirements, visit our MIPS page or chat with us using the blue chat icon below.

Policy Area Current Year 3 (Final Rule CY 2019) Year 4 (Proposed Rule CY 2020)
Performance Category Weights
  • Quality: 45%
  • Cost: 15%
  • Promoting Interoperability: 25%
  • Improvement Activities: 15%
  • Quality: 40%
  • Cost: 20%
  • Promoting Interoperability: 25%
  • Improvement Activities: 15%
Quality Performance Category Data Completeness Requirements
  • Medicare Part B Claims measures: 60% of Medicare Part B patients for the performance period
  • QCDR measures, MIPS CQMs, and eCQMs: 60% of clinician’s or group’s patients across all payers for the performance period
Call for Measures
CMS seeks measures that are:
  • Applicable
  • Feasible
  • Reliable
  • Valid at the individual clinician level
  • Different from existing measures
Measure Removal
  • A quality measure may be considered for removal if the measure is no longer meaningful, such as measures that are topped out
  • A measure would be considered for removal if a measure steward is no longer able to maintain the quality measure
QCDR Measure Requirements
  • QCDR measures must be beyond the measure concept phase of development
  • CMS will show a preference for QCDR measures that are outcome-based rather than clinical process measures
  • Measures should address significant variation in performance
  • QCDR measures are approved for use in MIPS for a single performance period
Measure Removal
There is no formal policy for measure removal, as QCDR measures must be submitted for CMS approval on an annual basis as part of the self-nomination process.
Data Completeness Requirements
  • Medicare Part B claims measures: 70% sample of Medicare Part B patients for the performance period
  • QCDR measures, MIPS CQMs, and eCQMs: 70% sample of clinician’s or group’s patients across all payers for the performance period
  • Note: If quality data is submitted selectively such that the data are unrepresentative of a MIPS eligible clinician or group’s performance, any such adat would not be true, accurate, or complete
Call for Measures
In addition to current requirements:
  • Measures submitted in response to Call for Measures would be required to demonstrate a link to existing and related cost measures and improvement activities as appropriate and feasible
Measure Removal
In addition to current measure removal criteria:
  • MIPS quality measures that do not meet case minimum and reporting volumes required for benchmarking for 2 consecutive years would be removed
  • We may consider a MIPS quality measure for removal if we determine it is not available for MIPS Quality reporting by or on behalf of all MIPS eligible clinicians (including via third party intermediaries)
QCDR Measure Requirements
In instances in which multiple, similar QCDR measures exist that warrant approval, we may provisionally approve the individual QCDR measures for 1 year with the condition that QCDRs address certain areas of duplication with other approved QCDR measures in order to be considered for the program in subsequent years. Duplicative QCDR measures would not be approved if QCDRs do not elect to harmonize identified measures as requested by CMS within the allotted timeframe.

QCDR Measure Rejections
CMS is proposing the following guidelines to help QCDRs understand when a QCDR measure would likely be rejected during the annual self-nomination process:

  • QCDR measures that are duplicative of an existing measure or one that has been removed from MIPS or legacy programs
  • Existing QCDR measures that are “topped out” (though these may be resubmitted in future years)
  • QCDR measures that are process-based (consideration given to the impact on the number of measures available for a specific specialty) or have no actionable quality action
  • Considerations and evaluation of the measure’s performance data, to determine whether performance variance exists
  • QCDR measures that have the potential for unintended consequences
  • QCDR measures that split a single clinical practice/action into several measures or that focus on rare events
  • QCDR measures that are “check-box” with no actionable quality action
  • Existing QCDR measures that have been in MIPS for two years and have failed to reach benchmarking thresholds due to low adoption (unless a plan to improve adoption is submitted and approved)
  • Whether the existing approved QCDR measure is no longer considered robust, in instances where new QCDR measures are considered to have a more vigorous quality action, where CMS preference is to include the new QCDR measure rather than requesting QCDR measure harmonization
  • QCDR measures with clinician attribution issues, where the quality action is not under the direct control of the reporting clinician. (that is, the quality aspect being measured cannot be attributed to the clinician or is not under the direct control of the reporting clinician)
  • QCDR measures that focus on rare events or “never events” in the measurement period
Improvement Activities Performance Category Definition of Rural Area
Rural area means a ZIP code designated as rural, using the most recent Health Resources and Services Administration (HRSA) Area Health Resource File data set available.

Patient-Centered Medical Home Criteria
To be eligible for Patient-Centered Medical Home designation, the practice must meet one of the following criteria:

  • The practice has received accreditation from one of four accreditation organizations that are nationally recognized:
    • The Accreditation Association for Ambulatory Healthcare
    • The National Committee for Quality Assurance (NCQA)
    • The Joint Commission
    • The Utilization Review Accreditation Commission (URAC); OR
  • The practice is participating in a Medicaid Medical Home Model or Medical Home Model; OR
  • The practice is a comparable specialty practice that has received the NCQA Patient Centered Specialty Recognition
Improvement Activities Inventory
  • Added 1 new criterion, “Include a public health emergency as determined by the Secretary”
  • Removed “Activities that may be considered for a Promoting Interoperability bonus”
CMS Study on Factors Associated with Reporting Quality Measures
MIPS eligible clinicians who successfully participate in the study receive full credit in the Improvement Activities performance category.

Removal of Improvement Activities
No formal policy but invited public comments on what criteria should be used to identify improvement activities for removal from the inventory.

Requirement for Improvement Activity Credit for Groups
Group or virtual group can attest to an improvement activity if at least one clinician in the TIN participates.

Definition of Rural Area
Rural area is proposed to mean a ZIP code designated as rural by the Federal Office of Rural Health Policy (FORHP) using the most recent FORHP Eligible ZIP Code file available.

Patient-Centered Medical Home Criteria
To be eligible for Patient-Centered Medical Home designation, the practice would need to meet one of the following criteria:

  • The practice has received accreditation from an accreditation organization that is nationally recognized
  • The practice is participating in a Medicaid Medical Home Model or Medical Home Model
  • The practice is a comparable specialty practice that has received recognition through a specialty recognition program offered through a nationally recognized accreditation organization; OR The practice has received accreditation from other certifying bodies that have certified a large number of medical organizations and meet national guidelines, as determined by the Secretary. The Secretary must determine that these certifying bodies must have 500 or more certified member practices, and require practices to include the following:
    1. Have a personal physician/clinician in a team-based practice
    2. Have a whole-person orientation
    3. Provide coordination or integrated care
    4. Focus on quality and safety
    5. Provide enhanced access
Improvement Activities Inventory
  • Addition of 2 new Improvement Activities
  • Modification of 7 existing Improvement Activities
  • Removal of 15 existing Improvement Activities

Please review Appendix 2 in the CY 2020 NPRM for a comprehensive look at the changes proposed to the inventory.

CMS Study on Factors Associated with Reporting Quality Measures
Study year 2019 (CY 2019) is the last year of the 3-year study, as stated in CY 2019 PFS final rule (83 FR 59776). CMS will not continue the study during the 2020 performance period. Final study results will be shared at a later date.

Removal of Improvement Activities
Establish factors to consider for removal of improvement activities from the Inventory. An activity would be considered for removal if:

  • It is duplicative of another activity
  • An alternative activity exists with stronger relationship to quality care or improvements in clinical practice
  • The activity does not align with current clinical guidelines or practice
  • The activity does not align with at least one meaningful measures area
  • The activity does not align with Quality, Cost, or Promoting Interoperability performance categories
  • There have been no attestations of the activity for 3 consecutive years
  • The activity is obsolete
Requirement for Improvement Activity Credit for Groups
  • Group or virtual group would be able to attest to an improvement activity when at least 50% of MIPS eligible clinicians (in the group or virtual group) participate in or perform the activity
  • At least 50% of a group’s NPIs must perform the same activity for the same continuous 90 days in the performance period
Promoting Interoperability Performance Category – Hospital-Based MIPS Eligible Clinicians in Groups

A group is identified as hospital-based and eligible for reweighting when 100% of the MIPS eligible clinicians in the group meet the definition of a hospital-based MIPS eligible clinician.

A group would be identified as hospital-based and eligible for reweighting if more than 75% of the NPIs in the group meet the definition of a hospital-based individual MIPS eligible clinician.

For non-patient facing groups (more than 75% of the MIPS-eligible clinicians in the group are classified as non-patient facing) we would automatically reweight the Promoting Interoperability performance category.

No change to definition of an individual hospital-based MIPS eligible clinician.

Promoting Interoperability Performance Category Objectives and Measures
  • One set of objectives and measures based on the 2015 Edition CEHRT
  • Four objectives: ePrescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange
  • Clinicians are required to report certain measures from each of the four objectives, unless an exclusion is claimed
  • PTwo new measures for the e-Prescribing objective: Query of Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement as optional with bonus points available
Objectives and Measures
  • CMS would require a yes/no response for the Query of PDMP measure
  • CMS would redistribute the points for the Support Electronic Referral Loops by Sending Health Information measure to the Provide Patients Access to Their Health Information measure if an exclusion is claimed
Cost Performance Category Measures
  • Total Per Capita Cost (TPCC)
  • Medicare Spending Per Beneficiary (MSPB)
  • 8 episode-based measures
Case Minimums
  • 10 for procedural episodes
  • 20 for acute inpatient medical condition episodes
Measure Attribution
  • All measures are attributed at the TIN/NPI level for both individuals and groups
  • Plurality of primary care services rendered by the clinician to determine attribution for the total per capita cost measure
  • Plurality of Part B services billed during the index admission to determine attribution for the MSPB measure
  • For procedural episodes, we attribute episodes to each MIPS eligible clinician who renders a trigger service (identified by HCPCS/CPT procedure codes)
  • For acute inpatient medical condition episodes, we attribute episodes to each MIPS eligible clinician who bills inpatient evaluation and management (E&M) claim lines during a trigger inpatient hospitalization under a TIN that renders at least 30% of the inpatient E&M claim lines in that hospitalization
Measures
  • TPCC measure (Revised)
  • MSPB-C (MSPB Clinician) measure (Name and specification Revised)
  • 8 existing episode-based measures
  • 10 new episode-based measures
Case Minimums
No changes.

Measure Attribution
  • Measure attribution would be different for individuals and groups and would be defined in the measure specifications
  • TPCC attribution would require E&M services to have an associated primary care service or a follow up E&M service from the same clinician group
  • TPCC attribution would exclude certain clinicians who primarily deliver certain non-primary care services (e.g. general surgery)
  • MSPB clinician attribution changes would have a different methodology for surgical and medical patients
  • No changes proposed for attribution in episode-based measures (existing and new)
Final Score Calculation: Performance Category Reweighting due to Data Integrity Issues
  • No policy to account for data integrity concerns
  • Several scenarios for reweighting have previously been finalized, including extreme and uncontrollable events (all performance categories) and hardship exemptions specific to the Promoting Interoperability performance category
  • We would reweight performance categories in rare events due to compromised data outside the control of the MIPS eligible clinician. MIPS eligible clinicians or third party intermediaries can inform CMS that they believe they are impacted by a relevant event by providing information on the event (CMS may also independently learn of qualifying events)
  • If we determine that reweighting for compromised data is appropriate, we would generally redistribute to the Promoting Interoperability performance category as well as the Quality performance category
  • In rare cases, we would redistribute to the Cost performance category
Performance Threshold / Additional Performance Threshold / Payment Adjustment
  • Performance Threshold is set at 30 points
  • Additional performance threshold set at 75 points for exceptional performance
  • As required by statute, the maximum negative payment adjustment is – 7%
  • Positive payment adjustments can be up to 7% (not including additional positive payment adjustments for exceptional performance) but are multiplied by a scaling factor to achieve budget neutrality, which could result in an adjustment above or below 7%
  • Performance Threshold would be set at 45 points
  • Additional performance threshold would be set at 80 points for exceptional performance
  • As required by statute, the maximum negative payment adjustment is -9%
  • Positive payment adjustments can be up to 9% (not including additional positive adjustments for exceptional performance) but are multiplied by a scaling factor to achieve budget neutrality, which could result in an adjustment above or below 9%
Targeted Review

MIPS eligible clinicians and groups may submit a targeted review request by September 30 following the release of the MIPS payment adjustment factor(s) with performance feedback.

All requests for targeted review would be required to be submitted within 60 days of the release of the MIPS payment adjustment factor(s) with performance feedback.

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July 30th, 2019 Categories: featured, MIPS Information, Patient Experience

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Celebrate National Healthcare Quality Week with SurveyVitals!

Group of doctors walking through hallway

October 21-27 is National Healthcare Quality Week. This week is dedicated by the National Association for Healthcare Quality to celebrating the contributions professionals have made to improve healthcare quality.

At SurveyVitals, we understand the value of improving patient safety and outcomes, performance and process improvement, and utilizing data analysis to drive improvement. In fact, these are the things that have shaped our solution. Since 2002, we have built into our system tools and features that help our clients make data-driven decisions to provide the highest quality of care to their patients. We have worked with industry experts and listened to the needs of our clients to be sure our solution helps achieve quality improvement goals.

We want to thank all of our clients for your hard work in providing a higher quality of care and better patient experience. Did you know there are a few ways you can celebrate with SurveyVitals?

  • Recognize top performers with SurveyVitals’ Friday kudos emails (SPSQ only), which spotlight weekly top performing staff members in your organization.
  • Celebrate your organization’s Top 10% Awards. These awards represent exceptional work toward higher healthcare quality and deserve special recognition! Top 10% Awards are awarded quarterly and annually to practices who rank in the top 10% for composite score for APSQ and SPSQ surveys.
  • Try out Challenge Mode in your portal. Issue a challenge to providers in your organization in any questions or question areas. Offer special recognition for whoever tops the leaderboard. Nothing encourages a higher quality of care quite like a bit of friendly competition!
  • Enroll providers in bi-weekly positive kudos emails.
  • Share your verified ratings online! With the new Public Review feature, you can proudly display verified patient ratings and comments to show the community the level of care you provide.

How does your organization plan on celebrating National Healthcare Quality Week?

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October 25th, 2018 Categories: featured, Patient Experience, Product Features

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Working MOCA 2.0? SurveyVitals Can Help

MOCA 2.0 anesthesia

The redesigned MOCA 2.0 (Maintenance of Certification in Anesthesiology) allows anesthesia diplomates to complete a variety of new activities to meet the Part 4 Quality Improvement requirement. Diplomates are required to earn a minimum of 50 points during their ten-year MOCA 2.0 cycle by choosing and completing quality improvement activities most relevant to their practice.

Where does SurveyVitals come in?

You may be able to use the SurveyVitals solution to fulfill the requirement by completing an improvement plan based on A) 360 professional reviews, or B) patient experience of care surveys. The point value for this activity is 1 point per hour spent on the activity, for a total of up to 25 points.

SurveyVitals’ Anesthesia 360° solution offers surveys for patients, practitioners, administrators, surgeons, and peers to give you a comprehensive look at patient and professional satisfaction.

Don’t know where to start? Your survey dashboard provides a detailed visual of areas scoring the lowest and receiving the most low-score alerts, allowing for quick identification of improvement opportunities. SurveyVitals’ robust reporting options allow you to easily track and measure improvement in these areas over time based on near real-time patient feedback.

How can I attest to meeting this requirement?

Diplomates must attest to the activity on the American Board of Anesthesiology (ABA) website using the ABA-approved template found here. Your SurveyVitals data can be used to summarize both the Data Summary and the Change in Practice.

More information about the MOCA 2.0 Part 4 requirement can be found on the ABA website.

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June 1st, 2018 Categories: Anesthesia, Product Features

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Accessing Your PQRS Feedback Report

Clock and pen and paper

Update: PQRS feedback reports for program year 2015 are now available (via CMS, 9/26/16). 2017 PQRS negative payment adjustment letters will be distributed shortly. Informal review will be open until November 30, 2016 at 11:59 P.M. EST.

What is PQRS?

The Physician Quality Reporting System (PQRS) is a program established and managed by the Centers for Medicare and Medicaid Services (CMS). The federal initiative aims to incentivize the reporting of quality data by individual Eligible Professionals (EPs) and group practices to Medicare by tying it to reimbursement rates. As all individual EP’s and group practices likely know by now, failing to satisfactorily report PQRS data will result in a negative payment adjustment under the Medicare Physician Fee Schedule (PFS). Those who reported satisfactorily for program year 2015 will avoid the negative 2% payment adjustment in 2017.

When will PQRS feedback reports for program year 2015 be available?

CMS announced that the PQRS feedback reports for program year 2015 will be available sometime this month, September 2016. These reports indicate whether or not your practice met all reporting requirements and if you’ll be subject to the future negative payment adjustment. Additionally, CMS announced that payment adjustment letters are projected to be sent in late summer or early fall. We recommend reviewing your feedback report as soon as made available to ensure you have enough time to properly review and request an informal review should your organization determine there was an error or CMS incorrectly assessed your practice. (Check back for updates!)

How to access your PQRS Feedback Report

To access your PQRS feedback report, you will need an Enterprise Identity Management System (EIDM) account, which can be established using the CMS Enterprise Portal at https://portal.cms.gov. Once logged in, select the “PV-PQRS” tab and the “Feedback Reports” option to view your reports. The PQRS feedback can be viewed at three different levels: provider level, reporting mechanism level, and PQRS measure level. Detailed user guides can be found on the QualityNet portal page.

Quality Resource and Usage Reports

In addition to PQRS feedback reports, Quality and Resource Use Reports(QRURs) are also made available through the CMS Enterprise Portal. These reports show performance on all of the quality and cost measures at the Taxpayer Identification Number (TIN) level. These results are used by CMS to calculate the 2017 Medicare Value-Based Payment Modifier. CMS makes two types of QRURs available: the Mid-Year QRUR and the Annual QRUR. The Mid-Year QRUR (MY-QRURs) was made available in April 2016 and was for informational purposes only. Groups of 2 or more EPs and physicians who are subject to the 2017 Value-Based Payment Modifier can use the Annual QRUR to see how the value modifier will apply to the Medicare PFS physician payments. The QRUR is for informational purposes for all other groups and solo practitioners.

Requesting an informal review

If you believe that there was an error or a negative payment adjustment was applied incorrectly, you can request an informal review of the payment adjustment determination. If the review process concludes that satisfactory reporting actually occurred, CMS will reverse the application of the negative payment adjustment. Unfortunately, the informal review decision is final. CMS has no formal appeals process in place at this time.

To submit an informal review request, visit the Quality Reporting Communication Support Page (CSP). Informal review requests for 2015 may be submitted in the fall of 2016, and CMS will announce when this page is available. Remember, the informal review period is limited so review your feedback and get your requests in as soon as the page is available.

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September 21st, 2016 Categories: featured, MIPS Information

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Press Release – SurveyVitals Partners with athenahealth’s ‘More Disruption Please’ Program

Press Release Athena Health
Timely Patient Feedback Can Help Providers Improve Their Patients’ Perceptions of Care and Reduce Malpractice Risk

SurveyVitals®, an automated, cost-effective quality and patient satisfaction survey solution provider, today announced a partnership with athenahealth® through athenahealth’s ‘More Disruption Please’ program. SurveyVitals is now part of the athenahealth Marketplace offerings. Together, the companies will work to link athenahealth’s growing network of more than 67,000 health care providers with SurveyVitals to improve their patients’ perceptions of care and reduce malpractice risk.

“SurveyVitals delivers a high-value quality tool,” said Bob Vosburgh, President of SurveyVitals. “Unlike traditional paper surveys, our real-time solution truly helps providers improve patients’ perceptions of care. Patient satisfaction measures are already being incorporated into many QCDRs (Qualified Clinical Data Registries) to meet PQRS (Physician Quality Reporting System) requirements. Now is the time to establish a quality program, and we can help. We’re thrilled to be integrated with athenahealth since it allows our mutual clients to start gathering patient feedback with just a few clicks. Detailed reporting and notifications guide providers toward real improvement.”

athenahealth is a cloud-based services company with a vision to build an information backbone to help make health care work as it should. This relationship will allow SurveyVitals to spread awareness of athenahealth’s cloud-based based services to clients who are looking for an EHR partner who delivers proven clinical and financial results so providers can stay focused on care.

About SurveyVitals

SurveyVitals helps improve patient care by administering automated, electronic patient satisfaction surveys on behalf of healthcare providers. They help practices and providers Get Better™. Now in their 13th year, they continue to disrupt the outdated model of expensive paper surveys that garner low response rates and provide delayed feedback. Their solution is used by thousands of providers across 58 specialties, and they have millions of surveys in their national baseline.

Read the official release.

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September 2nd, 2015 Categories: featured, Patient Experience, Press Release

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