QPP SURS Newsletter March 2019

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Last Call for 2019 MIPS Data!

If you are submitting 2018 MIPS data on behalf of yourself or your practice, or if you use a third-party vendor to collect data on your behalf, you or your vendor must sign in to qpp.cms.gov to submit your data by April 2, 2019 at 8pm EST. If you submitted quality performance category measure data via Part B claims, your Medicare Administrative Contractor (MAC) should have processed your claims within 60 days of the end of the performance year.

To submit your data, you must log into the data submission portal using your HCQIS Access Roles and Profile System (HARP) account (formerly known as an Enterprise Identity Data Management (EIDM) account). If you had an active EIDM account, your current user ID and password will automatically transition to HARP and allow you to log into your account. If you’ve forgotten or need to reset your EIDM password, or if you never had an EIDM account and need to register, you can do so on the QPP website log-in page. CMS has published a number of HARP-specific resources, including step-by-step instructions on how to set up an account, in the 2018 QPP Access User Guide.

The Quality Payment Program SURS Central Support Contractor held a webinar in February entitled, “Submitting Your 2018 MIPS Data: Advice for Solo and Small Group Practices.” This webinar provided an overview of data submission options across all performance categories and was specifically tailored to solo providers and small practices. For access to the recording, slides, and Q&A from this webinar, click here.

Additionally, CMS has a posted a series of videos to the QPP Resource Library to help clinicians understand how to manage and submit their 2018 MIPS data through the QPP website. For more information on MIPS data submission, see the 2018 Data Submission FAQs. If you need personalized assistance, contact your Technical Assistance Contractor for free support with your MIPS data submission. Find your local Technical Assistance Contractor here: https://qpp.cms.gov/about/small-underserved-rural-practices. Thank you for your great work in 2018!

Why Opt-in to MIPS in 2019?

In 2019, MIPS-eligible clinician types1 are required to participate in MIPS if they meet all three of the Low-Volume Threshold (LVT) eligibility criteria listed below:

  • Bill more than $90,000 a year in Medicare Part B allowed charges for covered professional services payable under the Physician Fee Schedule (PFS), and
  • Provide covered professional services to more than 200 Part B-enrolled individuals a year, and
  • Provide more than 200 covered professional services to Part B-enrolled individuals

However, MIPS-eligible clinician types have the choice to “opt-in” to MIPS if they meet one or two of the LVT criteria. This gives clinicians and groups who were previously excluded from MIPS the chance to participate even if they are not required to do so. To check your preliminary 2019 MIPS eligibility status, enter your 10-digit National Provider Identifier (NPI) in the Quality Payment Program (QPP) Participation Status Tool.

So what are the benefits of opting in to MIPS?

  1. Receive a payment adjustment! MIPS allows you the potential to get rewarded for providing high-quality care to your patients. In 2021, you could receive a maximum payment adjustment of up to 7% and an exceptional performer bonus of up to 0.5% based on your performance in 2019. It is important to note that payment adjustments are subject to budget neutrality provisions and may be lower than the maximum threshold amount. In addition, if you opt-in, you may be subject to a potential negative payment adjustment depending on your performance.
  2. Improve your patients’ health and quality of care. You will be scored based on your performance achieving key benchmarks for critical health care services relative to your peers. If you can identify creative, new ways to deliver better care at a lower cost, you will not only be receiving a higher payment adjustment, but more importantly you will be making your patients healthier.
  3. Showcase your high performance on Physician Compare. Get recognized for the high-quality care you already provide by participating in MIPS and having your performance ratings publicly available on the Physician Compare website. Clickhere for more details on the clinician performance information that will be available on Physician Compare.
  4. Increase your staff’s engagement. You can foster teamwork and collaboration among your staff by working together to select, track, and improve upon your MIPS measures.
  5. Obtain additional resources by joining a MIPS Alternative Payment Model (APM). By joining a MIPS APM, such as a Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO), you can receive preferential scoring, such as an automatic 100% on the Improvement Activities performance category. You can also benefit from the APM entity’s resources, including IT and data analytics capabilities. Want more help deciding whether you should opt-in to MIPS? Reach out to your local Technical Assistance Contractor for free in-person or virtual assistance. Find your local Technical Assistance Contractor here: https://qpp.cms.gov/about/small-underserved-rural-practices.

1MIPS Eligible Clinician Types include Physicians (including Doctors of medicine [KE3] [NS4], osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry), Osteopathic practitioners, Chiropractors, Physician assistants, Nurse practitioners, Clinical nurse specialists, Certified registered nurse anesthetists, Physical therapists, Occupational therapists, Clinical psychologists, Qualified speech-language pathologists, Qualified audiologists, and registered dietitians or nutrition professionals.

How Registries Can Help Your Practice Succeed in MIPS for 2019

Clinicians and groups have multiple options for how to collect and submit their MIPS data, you may want to consider a Qualified Registry or Qualified Clinical Data Registry (QC/QCDR) to collect and submit your MIPS data.

There are two types of registries, and both can submit MIPS measures on your behalf:

  • Qualified Registries; and
  • Qualified Clinical Data Registries (QCDRs).

The difference between the two is that Qualified Registries are limited to the standard MIPS measures, whereas CMS-approved QCDRs typically offer additional measures that are relevant to their specialty. QCDRs may be particularly helpful for specialties that have a limited set of standard MIPS measures from which they can choose.

Registries are beneficial for the following reasons:

  • Most registries can submit MIPS data to CMS on your behalf across all three performance categories (Quality, Promoting Interoperability, and Improvement Activities).
  • If you do not have an EHR, some registries will let you submit your data to them through a spreadsheet, and then they will submit your data electronically on your behalf.
  • Some registries can automatically pull data from compatible EHRs, saving you time and effort.
  • Some registries will let you submit data retroactively, which may be helpful if you started late in collecting data on quality measures.
  • QRs and QCDRs are required to provide MIPS-eligible clinicians with feedback reports at least four times a year, on all performance categories.
  • Using a registry can provide you with the data you need to monitor and improve your patient population health, and to get credit for MIPS population health improvement activities.

Choosing the right registry can also make your work easier. As Dr. John Wachter explained:

The registry I use is submitting all of our MIPS data for us. It’s very good – they’re very helpful, pretty much foolproof. You have your own account manager who usually responds within 24 hours and is very knowledgeable about all the changes that occur throughout the year.
John B. Wachter, O.D.

To choose a registry, consider these questions:

  • Which registries, if any, does your professional association recommend? Is your registry in good standing with CMS? Check the list of CMS-approved qualified registries (see link at the bottom of this article).
  • How much experience does your registry have? CMS regulations change every year, so if your registry has been around for a few years, it probably has some agility in responding to changes.
  • What measures does your registry support? Does it support measures that are meaningful for your practice and your patient population?
  • If you have an electronic health record (EHR):
    • How well does your registry communicate with your EHR (and vice-versa)?
    • Does your EHR support the same measures as your registry? If not, can you negotiate that feature with your EHR vendor?
  • Can the data be automatically sent to the registry by your EHR? If not, what are your options for reporting to the registry?
  • What is the cost? Consider not only the fees associated with your registry, but also the cost of time spent to submit data to the registry, retrieve data, and interpret reports.
  • Can you use a registry for purposes besides MIPS data submission? For example, can you use it to submit to other quality reporting programs? Does it provide you with dashboards that make it easy to prioritize population health interventions for your patients?
  • What do your fellow clinicians say about their experience with registries, especially with respect to customer service, data accuracy, ease of use, or other considerations that matter to you?
  • Does your registry have a data submission deadline that’s before the CMS submission deadline? Some registries may require you to submit data before the CMS deadline.

For the latest resources on QCDRs and Qualified Registries, visit the QPP Resource Library or use these links:

2019 QCDR list: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/156/2018%20QCDR%20Qualified%20Posting_FINALv14.xlsx

2019 Qualified Registry list: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/348/2019%20Qualified%20Registry%20Posting_Final_v1.0.xlsx

SURS Practice Spotlight: Lynn Karaffa

Processing all the information about MIPS and other quality improvement programs can feel overwhelming, but Lynn Karaffa, a practice manager for Campbell and Philbin Medical Associates in Pittsburgh, PA has it under control. In 2017, she helped her six-provider internal medicine group to attain a MIPS score of 92.9. Here are some of the strategies she deployed to get to that result:

  • Align your quality measures: In addition to MIPS reporting, Lynn’s practice reports quality measures to Medicare Advantage plans and two large medical systems. To keep the workload under control, Lynn focused her reporting on measures used across all these quality programs. Measures include body mass index (BMI) screening and follow-up, fall risk assessment screening, breast and colon cancer screening, and use of the prescription drug monitoring program (PDMP).
  • Leverage the state’s Prescription Drug Monitoring Program to improve patient care: Lynn says, “The PDMP is the next best thing to sliced bread. We can see when patients are visiting multiple providers, or using multiple pharmacies, or paying cash for their medications, and it pulls information from neighboring states, as well.” To keep patients safe, she also shared an online morphine equivalent calculator that her Technical Assistance Contractor had sent with the nurses in her practice. The nurses said this was exactly what they needed. You can find the calculator here.
  • Take advantage of all your resources: Lynn works closely with her electronic health record (EHR) vendor and participates in regular online education sessions with them to ensure that she is getting full credit for reporting MIPS measures. In addition, she has worked closely with her Technical Assistance Contractor, Quality Insights, to troubleshoot challenges with EHR and MIPS related reporting.
  • Be audit-ready: Quality Insights has helped Lynn organize her backup documentation in a binder so that she’s ready in case of an audit. As a result, Lynn says, “I can sleep at night because I’m confident we have what we need on file in case we’re audited.” What should be in that binder? Find out by downloading the Quality Insights audit binder template.

We hope these strategies will be helpful to you in 2019 and beyond!

How to Engage Senior Patients in Health Information Technology (HIT)

A common challenge expressed by practices preparing for MIPS is that it is difficult to engage older patients with health information technology, such as electronic health records and patient portals. Given that one of the required measures for the Promoting Interoperability performance category is “Provide Patients Electronic Access to Their Health Information” (i.e., PI_PEA_1), finding ways to effectively engage older patients with HIT is critical to earn points in the PI performance category. Moreover, making the effort to encourage older patients to use health IT can also earn you points under the Improvement Activities performance category to further improve your final score.

The challenge of engaging older patients in HIT is often attributed to the idea that older patients maintain negative attitudes towards technology and are reluctant to embrace HIT. While this stereotype may have some truth, this characterization is not universal. It may be that some older patients are hesitant to use HIT due to concerns regarding the security of HIT or the utility of the technology. Other older patients may have limited access to internet or smartphones to leverage HIT that is available to them and may need help using HIT. Accordingly, clinicians and practices may want to consider strategies to help older patients engage in HIT in ways that overcome some of the barriers listed above, which can then help to improve your practice’s MIPS performance.

A few strategies shared by your peers to engage older patients in HIT include:

  • Reach out to the older patient’s caregiver or younger relatives to train them on how the patient can access the patient portal or personal health record. Not only could they help the older patient access and navigate the technology, the patient may be more receptive to the utility of HIT if it is a family member educating them on the benefits.
  • Implement a process that encourages patients to register for the patient portal or complete required forms on the patient portal during check in. This strategy can be customized to your practice’s resources; for example, you could provide patients with a tablet specifically prepared to access the patient portal, or offer patients wireless access and instructions to set up their patient portal while they wait for their appointment.
  • Post lab results on the patient portal and notify patients that they can view the results by logging in.
  • Print out a take-home fact sheet for all older patients as they leave their appointment with clear and concise instructions on how to use the available HIT and its benefits.

While there may be older patients who do not wish to learn how to use HIT, consider trying out some of these strategies to encourage older patients to view their health information electronically, which can ultimately increase your practices’ MIPS score!

Monthly Observance — Colorectal Cancer Awareness Month

March is Colorectal Cancer Awareness Month, and a good reminder to talk to your patients about their risk for colorectal cancer. As the fourth most common type of cancer in the U.S., the Centers for Disease Control and Prevention (CDC) recommends regular screenings for men and women over the age of 50 to identify this cancer at the earliest stage possible. African Americans and minorities have a higher risk of colorectal cancers than other racial or ethnic groups, so it is important to help those at higher risk get regular screenings.

There are several MIPS quality measures that help providers address colorectal cancer. To help decrease the prevalence of this cancer, consider reporting on one of the quality measures below. For more information on colorectal cancer, click here: https://www.cdc.gov/cancer/colorectal/index.htm.

Upcoming Events


March 2019 LAN Webinar: MIPS Question and Answer Town Hall Event for Solo and small Group Practices

April 2019 LAN Webinar: Lessons Learned: How to Succeed in MIPS for Solo and Small Group Practices

Additional Upcoming Events and Links to Past Events

Upcoming and past CMS events related to MACRA, MIPS, and APMS will be listed here starting in the new year: https://qpp.cms.gov/.

Past QPP SURS events are listed here: https://qppsurs.wordpress.com/resources/

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