QPP SURS Newsletter October 2019

QPP SURS Quality Payment Program

IN THIS ISSUE

Upcoming Events

Doctor Talking to Patient

INFORMATION REGARDING UPCOMING EVENTS, ALONG WITH REGISTRATION INFORMATION, CAN BE FOUND BELOW:

December 2019 LAN Webinar: Implications for the Year 4 Final Rule for Solo and Small Group Practices

Additional Upcoming Events and Links to Past Events

Past QPP SURS events: https://qppsurs.com/webinar-resources/

How to Use your 2018 Performance Feedback

In July 2019, CMS posted MIPS performance feedback for the 2018 performance period for all MIPS-eligible clinicians who exceeded the low-volume threshold and/or participated voluntarily. While the targeted review period is ongoing, to view your current feedback, simply log in to the Quality Payment Program (QPP) website using your HCQIS Authorization Roles and Profile (HARP) credentials and review your performance feedback and final scores for all of your associated practices. If you are unsure of your HARP credentials, or still need to set up a HARP account, please see the QPP Access User Guide.

Your final score will be between 0 and 100 points, based on your performance in each of the four performance categories. You may also have received bonus points based on any special statuses for which you qualified, such as the small practice status, and the extent to which your practice’s scores improved for applicable Quality performance category measures reported during both 2017 and 2018. Your feedback also provides details on the performance of each individual clinician at your practice, as well as information on how your Cost Category score was calculated. For more information, check out the 2018 MIPS Scoring Guide as well as the CMS 2018 QPP Participation Infographic.

You can use your 2018 performance feedback and the educational materials below to help identify potential areas for improvement in subsequent MIPS performance periods. For example:

  • Consult the Performance Feedback Frequently Asked Questions (FAQs) to see answers to common questions. Additionally, check out the free resources provided by your Technical Assistance Contractor (TAC), including Telligen’s recent webinar, “2018 MIPS Performance Feedback Reports Are Available…What Should I Do Now?
  • If you received a low score in the Promoting Interoperability performance category, consider applying for a hardship exception for the current performance period. If you do not have an EHR, consider consulting free resources from your TAC, such as HSAG’s “No EHR MIPS Action Plan.”
  • Remember that practices with fewer than 15 MIPS-eligible clinicians or practices in Rural Health and Health Professional Shortage Areas will earn double points for each high- or medium-weighted activity submitted. That means you only need to complete one high-weight activity or two medium-weight activities to receive full credit for the Improvement Activity category.
  • If you want to make big changes to your MIPS score, consider creating a comprehensive MIPS action plan that sets goals for each of your performance categories. The American Medical Association has a MIPS Action Plan to get you started. You can also reach out to your (TAC) for individualized support. To find the right person to talk to in your region, check https://qpp.cms.gov/about/small-underserved-rural-practices.

Questions and Answers from the August 2019 QPP SURS LAN Webinar

The following questions were asked by the audience during the August 2019 LAN webinar, entitled “Maximizing Your Quality Score: Beyond the Basics for Solo and Small Group Practices.” For access to the full Q&A document and previous LAN webinar presentations, see the QPP SURS website.

1. What happens when almost all of the available measures are topped out and there are no others applicable?

A measure becomes topped out when clinician performance on that measure is so high and unvarying that meaningful distinctions and improvement in performance can no longer be made. There are several Quality measures that are topped out for 2019. You can find the topped out measures in the 2019 Quality Historic Benchmarks file.

If your practice’s measures are topped out, start by using the Explore Measures Tool and the 2019 Clinical Quality Measure Specifications and Supporting Documents to find other measures that your practice can report.

You may be able to find more measures by working with a third-party intermediary, like a Qualified Registry (QR) or a Qualified Clinical Data Registry (QCDR), to submit quality measure data for MIPS. A QR is an entity that collects clinical data from an individual MIPS-eligible clinician, group, or virtual group and submits it to CMS on their behalf. Clinicians work directly with their registry to submit data on the selected measures or specialty set of measures. A QCDR is a CMS-approved entity that collects clinical data on behalf of clinicians for data submission. Unlike QRs, QCDRs are not limited to standard measures within the Quality Payment Program, and can offer additional measures relevant to their specialty, which count towards MIPS scores. Sometimes measures are topped out in one submission method (for example, in claims) but not in another like QRs or QCDRs. QCDRs have additional CMS-approved quality measures available. Click here for the list of 2019 QRs for MIPS and click here for the 2019 list of QCDRs.

If none of these options work for you, and your practice submits fewer than six measures (or no outcome or high priority measure), CMS will use what is called the Eligibility Measure Applicability (EMA) process to determine if you could have submitted other clinically related measures. If CMS finds that there were no additional measures applicable to your practice, you won’t be held accountable for submitting fewer than the 6 required quality measures. If CMS discovers that your practice could have submitted additional clinically-related measures, but did not, it will affect your Quality performance category final score. For more information, see the 2018 Eligible Measure Applicability (EMA) Resources.

2. How do we find a specialty society registry?

MIPS eligible clinicians, groups, or virtual groups can work with a third-party intermediary, like a QR or a QCDR, to submit data for MIPS. Both QRs and QCDRs are required to provide performance feedback to participants at least quarterly, which can be helpful in monitoring your progress throughout the performance year. For a list of registries, please see the 2019 Qualified Registries Qualified Posting and the 2019 Qualified Clinical Data Registries (QCDRs) Qualified Posting. You can also reach out to your specialty society to find out if they have a registry.

3. Physician Compare seems to just have a “yes/no” regarding QPP participation. Is it ever going to have details on performance?

Physician Compare has performance information that shows how well clinicians and groups provide patients with the best recommended care. Star ratings for groups show how well they provided the recommended care to patients compared to the best performers for each measure. Physician Compare includes a publicly reported subset of MIPS measures as star ratings on Physician Compare profile pages. These measures include preventive care, general health and cancer screening, patient safety, care planning, diabetes, heart disease, respiratory diseases, and behavioral health. The 2017 Quality Payment Program performance information available in Physician Compare in 2019 includes:

  • 12 MIPS quality measures reported by groups
  • 8 Consumer Assessment for Healthcare Provider and Systems (CAHPS) for MIPS summary survey measures
  • 6 QCDR quality measures reported by groups
  • 11 QCDR quality measures reported by individual clinicians

Additional performance information may be available for clinicians and groups who reported information through a Qualified Clinical Data Registry (QCDR). At this time, not all clinicians and groups have performance information on their Physician Compare profile. Some of the information reported to Medicare is not currently available on Physician Compare profiles. For example, only measures deemed to meet the public reporting standards are considered for inclusion on the website. CMS intends to broaden the level of measures and details on the Physician Compare site over time.

For more information, please visit the CMS Performance Information and Physician Compare website.

How to Improve your 2019 Cost Performance Category Score

Understanding the Cost performance category and what you can do to optimize your cost score can have a big effect on your MIPS performance. As a reminder, the Cost performance category does not require your practice to submit any data. Instead, CMS will use Medicare administrative claims from the entire calendar year to calculate your performance on the Cost category measures. CMS assesses performance on Medicare Spending per Beneficiary (MSPB), Total per Capita Cost for All Attributed Beneficiaries, and eight episode-based cost measures for the category. For a full description of each measure and whether it applies to you, visit the QPP Explore Measures and Activities Tool.

Below are some tips that can help you maximize your Cost performance category score:

  • Consider selecting quality measures and improvement activities that could have a big impact on your Cost score, such as reducing preventable readmissions or improving transitions to care.
  • Accurate documentation and coding of Hierarchical Condition Category (HCC) codes is critical to success in the Cost performance category. Clinicians can earn up to 5 bonus points for the treatment of complex patients (based on a combination of the HCCs and the number of dually eligible patients treated). For more information, please see the Hierarchical Condition Categories Q&A Document created by TMF Health Quality Institute, one of the 11 Technical Assistance Contractors that supports small practices in Arkansas, Colorado, Kansas, Louisiana, Mississippi, Missouri, Oklahoma, Puerto Rico and Texas.
  • Schedule follow-up calls with your patients who were recently discharged from the hospital to discuss medication reconciliation or additional care. Educate your patients on when to seek urgent care and when to reach out to your practice for issues.
  • If you are a specialist, engage and work with primary care physicians to improve care coordination. If you are a primary care clinician, schedule annual wellness appointments to help address the complete health needs of your patients and ensure preventive care and screenings are up to date.

For more information about the 2019 Cost performance category, check out the 2019 Cost Performance Category Fact Sheet. For QPP-SURS specific guidance, see the recent webinar on “How to Maximize Your Score in the Cost Category: Practical Advice for Solo and Small Group Practices.” If you have more specific questions, reach out to your Technical Assistance Contractor. To find the right person to talk in your region, check https://qpp.cms.gov/about/small-underserved-rural-practices.

Resources for Specialists – New 2019 Specialty Guides

Specialty practices can sometimes struggle to identify relevant MIPS quality measures and improvement activities to report. To help specialty practices achieve success in MIPS, the Centers for Medicare & Medicaid Services (CMS) has published 2019 specialty guides, listing MIPS measures and activities for the following specialties:

Check out these specialty guides to identify relevant measures for your practice. For more resources tailored to your specialty, don’t forget to check out your national specialty association website, which often publishes MIPS resources designed exclusively for your specialty. Specialty associations also offer Qualified Registries (QR) and Qualified Clinical Data Registries (QCDRs) that help specialty practices identify and report MIPS measures.  For additional assistance, reach out to your local Technical Assistance Contractor for free, personalized assistance. To find your Technical Assistance Contractor, click here.

Monthly Observance – Breast Cancer Awareness Month

October is international Breast Cancer Awareness Month, and according to the World Health Organization, there are 1.4 million new cases of breast cancer and over 450,000 breast cancer-related deaths every year. Breast cancer is the most common form of cancer in women.

There are a number of 2019 MIPS quality measures that promote breast cancer screening and treatment. Review these measures below to determine if they are relevant for your practice:

  • Breast Cancer Screening (Quality ID 112): Percentage of women 50 – 74 years of age who had a mammogram to screen for breast cancer.
  • Image Confirmation of Successful Excision of Image-Localized Breast Lesion (Quality ID 262): Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy.
  • HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies (Quality ID 449): Percentage of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies.
  • Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy (Quality ID 450): Percentage of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving Trastuzumab.
  • Sentinel Lymph Node Biopsy for Invasive Breast Cancer (Quality ID 264): The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedure.

If applicable, consider reporting on one or more of these measures to help identify and treat breast cancer as early as possible and provide appropriate care to patients.

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