Editor’s Note: MACRA – the Medicare Access and CHIP Reauthorization Act of 2015 – replaces the Medicare Sustainable Growth Rate (SGR) with the Quality Payment Program (QPP), in an effort to emphasize the quality – over quantity – of services provided to patients. (Read Repertoire’s February issue for an overview of the law.)
The QPP, open to qualifying clinicians, is divided into two paths, of which clinicians must take one. One of these paths is the Merit-based Incentive Payment System, or MIPS.
Within MIPS, quality accounts for the biggest portion of data (60 percent) that physicians must report to the Centers for Medicare and Medicaid Services for reimbursement. That quality component was the subject of Repertoire’s April MACRA segment. Repertoire’s June MACRA segment focused on Advancing Care Information (ACI), which, at 25 percent, is the second largest portion of data physicians must report to CMS.
This month, Repertoire focuses on the last component of MIPS: Improvement Activities. At 15 percent, Improvement Activities is the smallest component of MIPS on which physicians must report data to CMS in 2017. (Beginning in 2018, a fourth category – cost – will be implemented.) Here is a summary of what the Improvement Activities category entails.
Doctors rated on Improvement Activities
The Improvement Activities performance category within MIPS assesses providers’ participation in activities that improve clinical practice. Examples of these activities include ongoing care coordination, clinician and patient shared decision-making, regular implementation of patient safety practices, and expanding practice access.
Doctors can choose from activities listed under the Improvement Activities inventory, which divides the activities into nine subcategories:
- Expanded Practice Access
- Population Management
- Care Coordination
- Beneficiary Engagement
- Patient Safety and Practice Assessment
- Participation in an APM (Alternative Payment Model)
- Achieving Health Equity
- Integrating Behavioral and Mental Health
- Emergency Preparedness and Response
There are no subcategory reporting requirements, so providers can choose to implement the activities that are most meaningful to their practice. That is, they do not have to select activities in each subcategory or select activities from a certain number of subcategories. They must complete improvement activities for a minimum of 90 days to earn credit for them. In this case, “completing” means implementing the activity and attesting that the practice has done so.
How providers are scored
Groups with more than 15 clinicians:
Each activity is weighted either medium or high. To get the maximum score of 40 points for the Improvement Activities score, large practices may select any of these combinations:
- Two high-weighted activities
- One high-weighted activity and two medium-weighted activities
- Up to four medium-weighted activities
Each medium-weighted activity is worth 10 points of the total Improvement Activities performance category score, and each high-weighted activity is worth 20 points of the total score.
Groups with 15 or fewer clinicians, non-patient-facing clinicians and/or clinicians located in a rural area or HPSA (Health Professional Shortage Area):
Again, each activity is weighted either medium or high. To achieve the maximum 40 points for the Improvement Activities score, small practices may select either of these combinations:
- One high-weighted activity
- Two medium-weighted activities
For these clinicians, each medium-weighted activity is worth 20 points of the total Improvement Activities performance category score, and a high-weighted activity is worth 40 points.
(Source: Centers for Medicare and Medicaid Services. To view CMS’ fact sheet, visit https://qpp.cms.gov/docs/QPP_2017_Improvement_Activities_Fact_Sheet.pdf.)
Examples of improvement activities
MIPS-eligible care providers have 92 improvement activities from which to choose. Each activity, which falls under one of nine subcategories, is weighted either medium or high. Depending on its size, a practice must choose a certain combination of activities to implement to earn the maximum 40 points available in this MIPS component. For example:
Practices with more than 15 doctors
Since each medium-weighted activity is worth 10 points, and each high-weighted activity is worth 20 points for large groups, these practices might choose to implement a combination such as:
- Collection and use of patient experience and satisfaction data on access (medium weight; 10 points)
- Implementation of medication management practice improvements (medium weight; 10 points)
- Engagement of new Medicaid patients and follow-up (high weight; 20 points)
Practices with 15 or fewer doctors
Using the same measures from above, since each medium-weighted activity is worth 20 points for smaller practices, and each high-weighted activity is worth 40 points, these practices might implement a combination such as:
- Collection and use of patient experience and satisfaction data on access (medium weight; 20 points)
- Implementation of medication management practice improvements (medium weight; 20 points)
OR
- Engagement of new Medicaid patients and follow-up (high weight; 40 points)
(For more information on the Improvement Activities category, or to view the activities, visit https://qpp.cms.gov/mips/improvement-activities.)
‘Virtual physician groups’ possible in 2018
The Quality Payment Program, established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), began in 2017, known as the transition year. In preparation for Year 2, the Centers for Medicare & Medicaid Services this spring proposed changes to the program, to be put into place in 2018.
One of the biggest proposals for Year 2 is Virtual Group participation. Virtual Groups would be composed of solo practitioners and groups of 10 or fewer eligible clinicians, eligible to participate in MIPS, who come together “virtually” with at least one other such solo practitioner or group to participate in the Merit-based Incentive Payment System (MIPS) for a performance period of a year.
Other proposals for Year 2 include:
- Increasing the low-volume threshold so that more small practices and eligible clinicians in rural and Health Professional Shortage Areas (HPSAs) are exempt from MIPS participation.
- Continuing to allow the use of 2014 Edition CEHRT (Certified Electronic Health Record Technology), while encouraging the use of 2015 edition CEHRT.
- Adding bonus points in the scoring methodology for caring for complex patients.
- Incorporating MIPS performance improvement in scoring quality performance.
- Incorporating the option to use facility-based scoring for facility-based clinicians.
CMS is also proposing changes for clinicians in small practices that would add a new hardship exception for clinicians in small practices under the Advancing Care Information performance category, and add bonus points to the Final Score of clinicians in small practices.
For a table describing the proposed changes, go to https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Proposed-rule-fact-sheet.pdf
Help for your docs with MACRA
Your physician customers can get some free, hands-on help understanding and participating in Medicare’s Quality Payment Program – either the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Model (APM track).
Smaller practices
Small practices of 15 or fewer clinicians can get help from one of 11 local organizations. (Practices in rural locations, health professional shortages areas and medically underserved areas will be helped first.) They are:
States Organization
| Illinois, Indiana, Kentucky, Ohio, Michigan, Minnesota, Wisconsin | Altarum (qppinfo@altarum.org) |
| Florida, Georgia, North Carolina, South Carolina | Alliant GMCF (QPPSURS@alliantquality.org) |
| Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont | Healthcentric Advisors (NEQPPSURS@healthcentricadviors.org) |
| Arizona, California, New Mexico | Health Services Advisory Group (HSAG) (HSAGOPPSupport@hsag.com), 844-472-4227 |
| New York | IPRO (ny-qppsupport@atlanticquality.org) |
| District of Columbia | IPRO (dc-qppsupport@atlanticquality.org) |
| Maryland | IPRO (MD-QPPsupport@atlanticquality.org) |
| Virginia | IPRO (Virginia) |
| Nevada, Oregon, Utah | Network for Regional Healthcare Improvement (QPP@healthinsight.org) |
| Alaska, Montana, Wyoming | Network for Regional Healthcare Improvement (QualityPaymentHelp@mpqhf.org) |
| Alabama, Tennessee | QSource (techassist@qsource.org) |
| Idaho, Washington | Qualis (QPP-SURS@qualishealth.org), 877-560-2618 |
| Delaware, New Jersey, Pennsylvania, West Virginia | Quality Insights (WVMI) (qpp-surs@qualityinsights.org), 877-497-5065) |
| Iowa, Nebraska, North Dakota, South Dakota | Telligen (qpp-surs@telligen.com, 844-358-4021) |
| Puerto Rico | TMF (QPP-SURS@tmf.org) |
For larger practices
Practices with 16 or more clinicians can get support from these organizations. (For email addresses of each, go to http://qioprogram.org/contact-zones?map=qin)
| North Carolina, Georgia | Alliant GMCF |
| New York, South Carolina | Atlantic Quality Improvement Network |
| Alabama, Indiana, Kentucky, Mississippi, Tennessee | atom Alliance |
| Kansas, Nebraska, North Dakota, South Dakota | Great Plains Quality Innovation Network |
| Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont | Healthcentric Advisors |
| Nevada, New Mexico, Oregon, Utah | Healthinsight |
| Arizona, California, Florida, Ohio | HSAG |
| Michigan, Minnesota, Wisconsin | Lake Superior Quality Innovation Network |
| Montana, Wyoming | Mountain Pacific Quality Health Foundation |
| Idaho, Washington | Qualis |
| Delaware, Louisiana, Maryland, New Jersey, Pennsylvania, West Virginia | Quality Insights Quality Innovation Network |
| Colorado, Illinois, Iowa | Telligen |
| Arkansas, Missouri, Oklahoma, Texas | TMF |
| Maryland, Virginia | VHQC |
Source: Centers for Medicare & Medicaid Services, https://qpp.cms.gov/docs/QPP_Technical_Assistance_Resource_Guide.pdf