maximizing mips advancing care information (aci) … · 11/10/2017 · submit more than base score...

QUALITY PAYMENT PROGRAM SMALL UNDERSERVED RURAL SUPPORT (QPP SURS) LAN WEBINAROCTOBER 17, 3:30-4:30 ET; OCTOBER 19, 11:00-12:00 ET

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MAXIMIZING MIPS ADVANCING CARE INFORMATION (ACI) SCORES FOR SMALL GROUP PRACTICES AND SOLO CLINICIANS

MAXIMIZING MIPS ACI SCORES

HOUSEKEEPING ANNOUNCEMENTS

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For assistance, enter your issue in the chat box

To ask a question, enter your inquiry in the chat box, or press *# to enter the queue on the phone

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POLLING QUESTIONWhat is your role?▸

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A clinician working in a practice with 15 or fewer clinicians

Non clinical staff from a practice with 15 or fewer clinicians

A clinician working in a practice with more than 15 clinicians

Non clinical staff in a practice with more than 15 clinicians

Quality Payment Program contractor

Other person helping practices prepare for MIPS

Other

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CMS WELCOME

Brenda Gentles, RN, BS, MS

Division of ESRD, Population & Community Health

Centers for Medicare & Medicaid Services

QPP- SURS Central Support Contractor COR

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Denise Scott, MM, RN-BC, CMHP, Director of

Ambulatory Services, Medisolv

Bruce Spurlock, MDPresident & CEO,Cynosure Health

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Patricia Kosednar, PMP, CPHER, CPHIMS,

Consultant, Health Technology

Services/Mountain-Pacific

Mary Atkinson Smith, DNP, FNP-BC, ONP-C, Starkville Orthopedic

Clinic Nurses Lead, Founder

Deanna Graham, BS, Quality Improvement

Principal, Qualis Health


SETTING THE STAGE▸

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Event Focus: ▸▸

Leveraging your EHR to maximize your MIPS scoreFocus is on what works best for SMALL group practices—requirements mentioned are for practices of 15 or fewer participants and solo eligible clinicians

Begin with very quick overview:▸▸▸

Resources for free support and answers to your questionsOverview the WHY, WHO, WHEN, WHAT & WHEREMajor focus: HOW

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RESOURCES FOR FREE SUPPORT7

Small, Underserved & Rural Direct Support Organizations (DSO)

Free technical assistance and advice available for small practices from CMS-funded DSOs. Contact information for each DSO at: https://qpp.cms.gov/docs/QPP_Support_for_Small_Practices.pdf

• General information about QPP and MIPS for all practices participating in MIPS or an APM: https://qpp.cms.gov/

• Questions to CMS about the QPP Program:[email protected]

• Sources of support for larger practices and APM participants described in: https://qpp.cms.gov/docs/QPP_Technical_Assistance_Resource_Guide.pdf

• More details provided on slide 38

https://qpp.cms.gov/docs/QPP_Support_for_Small_Practices.pdf

https://qpp.cms.gov/

mailto:[email protected]

https://qpp.cms.gov/docs/QPP_Technical_Assistance_Resource_Guide.pdf


WHY MIPS AND ACI MATTER▸

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Aligning payments with high quality & efficient care is in the best interest of patients and the healthcare systemFinances, public reputation & preparing for the future make MIPS important even if financial impact is not largeUsing EHRs and other IT systems is essential for efficient & effective patient care, increased patient safety and sustainable operations

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WHO MIPS AFFECTS▸▸▸

All clinicians and practices that meet minimum Medicare volume thresholdsGroups, individuals and virtual groupsClinicians participating in an advanced APM are excluded

▸ Eligibility requirements may change in 2018 but no reason to stop preparing (see https://qpp.cms.gov/docs/QPP_Proposed_Rule_Slide_Presentation.pdf for a summary of proposed 2018 rule)

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Check your eligibility at: QPP.CMS.GOV

https://qpp.cms.gov/docs/QPP_Proposed_Rule_Slide_Presentation.pdf


HOW, WHEN AND WHERE TO SUBMIT MIPS INFORMATION▸

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Choose to submit through a qualified registry, a QCDR, an EHR, attestation or using claims data

Your submission is due to CMS by March 31, 2018 but submission can begin January 2, 2018 and starting sooner than March is recommended

BUT: Doing the work to generate the information you’ll need to submit should have begun by Oct. 2, 2017 (but you can still avoid a penalty)

Deadlines for particular EHR or Registry vendors may be earlier than March 31, so it’s important to check

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FOR FULL PARTICIPATION, WHAT MUST BE SUBMITTED?▸

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6 quality measures (one outcome) for full participation

Cost category not required this year

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Attest to 1 high-weighted or 2 medium-weighted improvement activities (different requirements for clinicians in larger practices or those not in rural or medically underserved areas)Submit more than base score ACI measures for full participationOptions for test pace or to submit data for 90 days exist


QUESTION:

What’s the bare minimum I need to do in order to avoid a penalty?

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AVOIDING THE PENALTY IS EASY▸

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One quality measure on one patient, one time or one improvement activity (sometimes called “test method/test pace”)

Submit using your EHR, a qualified registry, QCDR, attestation or using claims data

Doing more than the bare minimum is better:▸

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Helps you to prepare for future years

Possibility of earning bonuses

Reputation of your practice affected by public reporting of MIPS data

Quality measurement and reporting benefits your patients

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POLLING QUESTIONWhat describes your practice’s readiness to earn a good MIPS ACI score?

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We are considering an EHR but do not have one at this time

We are planning to get a certified EHR or to transition to one from our current EHR

▸We have a certified EHR but aren’t fully sure how to use it to meet MIPS requirements

▸We have already done meaningful use and are fairly prepared or very prepared to earn a high MIPS ACI score

▸While we haven’t done meaningful use, we still are fairly prepared or very prepared to earn a high MIPS ACI score

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QUESTION:

What if I don’t have an EHR or if my EHR isn’t certified?

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You can check online to see if your EHR is certified at:

https://chpl.healthit.gov/#/search

https://chpl.healthit.gov/#/search


WITHOUT A CERTIFIED EHR . . .▸

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You can still avoid a penalty for 2017 by reporting a single quality measure or improvement activity (test pace)

You may be eligible for a hardship exemption (but these are rare)

You may lose money in future years and struggle to be efficient, safe and to provide high quality care. Without an EHR you may fall behind practices that employ them.

EHR implementation has value for small practices; Discuss EHR options with your DSO if you don’t have one .

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QUESTION:

What are the Advancing Care Information (ACI) requirements and why are there two sets of them?

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ACI REQUIREMENTS OVERVIEW18


ACI REQUIREMENTS OVERVIEW19


QUESTION:

Can you explain the base requirements we have to meet to get any ACI points?

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ACI BASE REQUIREMENTS AND WHY THEY MATTER

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Advancing Care InformationObjectives and Measures

Base Score Required Measures

Measure ResultSecurity Risk Analysis Yese-Prescribing 1 patientProvide Patient Access 1 patientSend a Summary of Care 1 patientRequest/Accept a Summary of Care

1 patient

2017 Transition Advancing Care Information Objectives and Measures

Base Score Required Measures

Measure ResultSecurity Risk Analysis Yese-Prescribing 1 patientProvide Patient Access 1 patientHealth Information Exchange 1 patient


QUESTION:

What is the security risk assessment and won’t my EHR vendor handle this?

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SECURITY RISK ASSESSMENT:23


SECURITY RISK ASSESSMENT:24

Useful resources: https://www.healthit.gov/providers-professionals/security-risk-assessment-tool (source of security risk area tables)https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/2016_SecurityRiskAnalysis.pdf

https://www.healthit.gov/providers-professionals/security-risk-assessment-tool

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/2016_SecurityRiskAnalysis.pdf


OTHER ACI BASE REQUIREMENTS25


QUESTION:

If we can meet the base ACI requirements, what do we need to do to meet the advanced requirements and even get bonus points?

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ACI PERFORMANCE MEASURE REQUIREMENTS27


ACI PERFORMANCE MEASURES28


ACI BONUS POINT OPPORTUNITIES29


CEHRT IMPROVEMENT ACTIVITIES FOR ACI BONUS POINTS▸ Using the following Certified EHR Technology (CEHRT) functionalities as part of

your Improvement Activities makes you eligible for ACI bonus points:

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Providing or sharing information via your patient portal

Communication with patients via secure messaging

Providing/sharing summary of care documents with patients or other providers

Implementing clinical decision support rules (CDS)

Providing patient specific education

▸ More information on the CMS ACI Fact Sheet

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https://qpp.cms.gov/docs/QPP_ACI_Fact_Sheet.pdf


QUESTION:I think I understand these requirements but I’m not sure how to get my EHR to perform the tasks or to provide the information I need. What should I do?

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TRANSITIONING FROM THE WHAT TO THE HOW▸

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Good news: Certified EHRs capture the information you need but you still need to access it and make sure that it’s accurate

First step: generate a report from your EHR

Next: Validate to ensure the reports are generating the right numbers

Clarify: Review the report with your care team to validate and identify gaps

Understand: How and when your vendor will transmit information from your EHR to CMS

Get help: Seek support & advice from your DSO and EHR vendor

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QUESTION:

This is a lot of work, so how can I do this as efficiently as possible?

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TIPS FOR MAXIMIZING EFFICIENCY34

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Use EHR reports to monitor your quality measures and improvement activities and identify entry errors or care processes that should be fixed

Choose measures that align with other quality program or quality improvement goals

Choose measures and improvement activities that align and can give you points in multiple MIPS categories


EXAMPLES OF MAXIMIZING EFFICIENCY35


QUESTION:

What common mistakes do you see small practices making as they work to get a good ACI score?

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COMMON MISTAKES TO AVOID▸

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Waiting too long to get started

Failing to report all base measures – without these ACI score = 0

Not understanding the difference between the ACI measures and not using the transition measures for 2017

Ensure that patient education, view download transmit, and secure messaging are being documented correctly now

Missing 10 easy points available for reporting to an Immunization Registry

Not selecting a bonus-eligible Improvement Activity measure

Failing to get free help from your DSO and EHR vendor

▸ Not accessing MIPS guidance resources from CMS

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FREE RESOURCES FOR ASSISTANCE FROM CMS▸

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QPP website: https://qpp.cms.gov/--includes information tailored for the needs of small practices https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-Events.htmlContact the Quality Program at: [email protected] or call 1-866-288-8292Small Underserved Rural Support Direct Support Organizations (see list on slide 7)▸▸▸

Contact information on available at: https://qpp.cms.gov/docs/QPP_Support_for_Small_Practices.pdfAvailable websites of each Direct Support OrganizationTypes of help: needs assessments, webinars, technical support, links to peers you can talk with, assistance

getting signed up to report through an approved channel that meets your practices needs▸FREE Technical Assistance funded by CMS is also available for larger group practices and for clinicians interested in participating in an Alternative Payment Model. More information on those programs is available at: https://qpp.cms.gov/docs/QPP_Technical_Assistance_Resource_Guide.pdf

Benefits of Electronic Health Records Other national events about Quality Payment ProgramOther national webinars focused on small practices

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https://qpp.cms.gov/

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-Events.html

mailto:[email protected]

https://qpp.cms.gov/docs/QPP_Support_for_Small_Practices.pdf

https://qpp.cms.gov/docs/QPP_Technical_Assistance_Resource_Guide.pdf

https://www.healthit.gov/providers-professionals/benefits-electronic-health-records-ehrs

CHOOSING QUALITY MEASURES & IMPROVEMENT ACTIVITIES

POLLING QUESTIONIn the next three months, what describes your plans for participating in MIPS for the transition year 2017?▸▸▸▸

We’re already totally prepared

We’re taking steps that will allow us to do full year reporting

We’re taking steps that will allow us to do partial year reporting

We’re planning to use the Test Pace to avoid penalty in the 2017 transition year

▸We’re just going to accept the penalty

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FINAL POLLING QUESTIONIf you are struggling to participate in MIPs for 2017, what are the largest challenges you are encountering?

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WRAP-UP ACTIVITIES▸▸

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Links to the recording of the event available at: https://qppsurs.wordpress.com/resources/

Future webinar topics and timeframe:

▸ November MIPS Questions and Answers Town Hall Event

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November 14 at 11:00 am ET

November 16 at 3:30 pm ET

Please provide feedback on this event: Feedback Form

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Some of the materials contained in these slides is drawn from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-ACI-Deep-Dive-Webinar-Slides.pdf. Slide decks created by event panelists also provided information reflected in this presentation. The input from project panelists is gratefully acknowledged.

Other documents on the QPP.CMS.GOV website provide additional detail about the MIPS program.

Disclaimer: This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

https://qppsurs.wordpress.com/resources/

https://docs.google.com/forms/d/e/1FAIpQLSfl6uhItVpmHkisiMbN76s2ITpJw5wcQsB_ewCmd3xI0WMg9A/viewform?usp=sf_link

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-ACI-Deep-Dive-Webinar-Slides.pdf

maximizing mips advancing care information (aci) … · 11/10/2017 · submit more than base score...

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