December 06, 2016
I think it's time to finally tackle the part of MIPS that I've been avoiding. It's the category that Dr. Ketchersid deemed the overnight MACRA sensation due to its large impact on your MIPS score. It's also arguably one of the more confusing categories to understand. Do you know which one I'm talking about? The title probably gave it away, but today we will be digging into the world of quality!
MIPS composite score recap
As you probably read by now, if you are a clinician in the MIPS track next
year, your MIPS composite score will be made up of 4 different categories
(as shown below). Notice that the quality category is worth over double any
of the other categories!
In order to get a perfect 60% in quality, a clinician will need to earn a
total of 60 (or 70) points.
Clinicians will earn points in the quality category of MIPS by their performance
on quality measures and collecting bonus points.
Most clinicians must select 6 of about 300 individual quality measures (across
any combination of quality domains) where 1 must either be:
An outcomes measure or
A high-priority measure (if an outcomes measure is unavailable)
In addition to the 6 measures, CMS will calculate (through claims data) on
the "all-cause hospital readmission" measure for groups with 16 or more clinicians
and a minimum of 200 cases. This measure is also worth up to 10 points. Groups
below that threshold will not have this measure included.
If you cannot find 6 applicable measures, CMS will reweight your quality
category based on the number of measures you are able to select. If you choose
not to submit any measures at all, you will get a zero in the entire category!
Another alternative would be to report all measures in a "specialty set".
A specialty set is similar to the "measures group" concept in today's PQRS
world. Essentially CMS tried to ease measure selection by assembling sets
of measures for specific specialties found under the American Board of Medical
If the measure set contains fewer than 6 measures, MIPS eligible clinicians
will only need to report on all available measures within the set. If the
specialty set contains more than 6 measures, the clinician will only need
to select 6.
Sorry nephrologists, much to my dismay, there is no specialty set for you.
Our beloved CKD measures group has sailed off into the sunset. Instead, you
will need to dig through the full list of measures to find ones most suitable
for your scope of practice.
Which patients do I report on?
Your reporting all depends on which submission route you decide to take!
Individual MIPS eligible clinicians or groups submitting data on quality
measures using QCDRs, using qualified registries, or via EHR need to report
on at least 50 percent of the MIPS eligible clinician or group's patients
that meet the measure's denominator criteria, regardless of payer for the
performance period. In other words, clinicians will need to send quality
data for both Medicare and non-Medicare patients.During the transition year
in 2017, clinicians who do not submit at least 50 percent of their patients
for each measure will receive the minimum score of 3 points per measure
Individual MIPS eligible clinicians submitting quality measures data
using Medicare Part B claims would report on at least 50 percent of the
Medicare Part B patients seen during the performance period to which the
measure applies. Doubt many nephrologists will go this route!
Groups submitting quality measures data using the CMS Web Interface
or a CMS-approved survey vendor to report the CAHPS for MIPS survey would
need to meet the data submission requirements on the sample of the Medicare
Part B patients CMS provides.
The most popular option from the list above will be the first one. You will
need understand how the measure is calculated and ensure that 50 percent of
your patients who meet the denominator criteria are being reported. CMS will
ramp up the data completeness threshold to 60 percent in 2018.
Let's take a look at an example for a little help:
The "Diabetes Foot Exam" clinical quality measure denominator looks for
all patients (ages 18-75) with type 1 or type 2 diabetes who were seen for
a specific type of visit during the reporting period. If you choose this measure,
50 percent of your type 1 or type 2 diabetes patients that meet the age and
encounter requirements will need to be reported on for the performance period
You will want to ensure that the tool you are using (EHR, Quality Registry,
or QCDR) is tracking all of your outpatient encounters to be on the safe side.
It should also be able to automatically calculate the measures you select.
In addition to all of this, you will need a minimum of 20 cases per measure.
If you do not have at least 20 cases and still decide to report the measure,
CMS will award you a maximum of 3 points (in 2017 only).
Quality scoring and earning points
Now that you understand how to select measures and how many patients to
submit measures for, let's examine how you will earn points for these measures.
This is where things get even more complicated.
Each measure is worth up to 10 decile points. Each year, CMS will publish
deciles for each measure based on national performance in a baseline period
(which is two years prior to the performance period). Performance is compared
and points are assigned based on the decile range in which the performance
data is located, all receiving at least 1 point depending on the comparison
Take a look at the example below. Let's assume it is for the "Diabetes Foot
Exam" measure in which you scored a 79% during the reporting period. In this
case, you would get 9.0 decile points for the measure (out of a possible 10
You would go through this exercise with the remainder of the 6 measures you
selected to estimate your total quality score. The benchmarks for each measure
will be published prior to the performance period.
Now for those of you wanting to report on newer measures-buyers beware!
For newer measures, CMS doesn't have enough data to benchmark in order to
assign deciles. Each benchmark must have a minimum of 20 individual clinicians
or groups reporting the measure in order to meet the data completeness requirement
and minimum case size criteria and performance greater than 0.
Therefore, CMS will have to use data from the current performance period
to create measure benchmarks. This information won't be available until after
the end of the performance period (and in turn you will not be able to predict
how well you did).
To overly complicate things, in 2017 only, MIPS quality measures that do
not have a benchmark will not be scored based on performance. Instead, these
measures will receive a maximum of 3 points. Because of this, if you are submitting
data for MIPS next year and are trying to earn incentive dollars (vs avoid
a penalty), new measures may not be the way to go.
Lastly, if you are at the end of a reporting period and still have a 0 percent
in some of your selected measures, report them anyway! In 2017, CMS will award
a minimum of 3 points just for submitting the measure (assuming you reported
on 50 percent of patients in that measure's denominator).
Still not doing so hot? Bonus points are available!
Much like in ACI, clinicians can earn bonus points to help increase their
total quality score. Bonus points can be earned 2 different ways:
Reporting on additional outcomes/high-priority measures: Two bonus points
will be awarded for every additional outcomes measure (outside of the required)
and patient experience measure selected. One bonus point will be awarded
for every high priority measure selected. This bonus opportunity will be
capped at 10 points.
End-to-end reporting: One bonus point will be awarded for each measure
if an eligible clinician uses certified EHR technology to capture and report
quality data to CMS. This bonus opportunity will be capped at 10 points.
What should you do?
Before you start selecting measures, you will need to know if your practice
is participating in an alternative payment model (APM). If it is, then most
likely your measures have already been selected on your behalf and your quality
score will be submitted by the APM.
If you are not in an APM, choose your measures wisely. Take a look at your
historic Meaningful Use performance data to see how well you've been doing
on measures you are already familiar with. This will allow you to see where
you can improve for next year. Otherwise, you could sift through the 300 measures
available in the final rule to find new measures.
Some important things to keep in mind:
Not all measures can be reported through your EHR. Some can only be reported
through a registry, which could involve extra setup and interface fees
You are competing against everyone else who reports that measure (you are
not given special treatment because you are a specialist)
Due to the transition year next year, CMS is allowing you to completely
skip this category as long as you report on 1 improvement activity or the
base measures under Advancing Care Information. Otherwise you can report just
1 quality measure in order to avoid a penalty as well.
Phew! There is still so much more to cover on this topic but I don't want
to nudge the monster too hard. Hopefully this is enough information to get
you started-and as always, expect us to dive deeper in a future blog.
What do you think of the largest MIPS category? We'd love to hear your opinions
Diana Strubler, Policy and Standards Senior Manager, joined
Acumen in 2010 as an EHR trainer then quickly moved into the role of certification
and health IT standards subject matter expert. She has successfully led Acumen
through three certifications while also guiding our company and customers
through the world of Meaningful Use, ICD-10 and PQRS. http://acumenmd.com