How Do Improvement Activities fit into MIPS?

The Merit-based Incentive Payment System (MIPS) is a four-part program which combines three existing initiatives (Quality Reporting, Advancing Care Information, and Cost) with a new venture: Improvement Activities (IAs). IAs account for 15 percent of one’s total MIPS score if completing a full year’s reporting for all programs.

Can I “Pick my Pace” with Improvement Activities?

Yes. If you want to do the Test option by doing one IA for one patient, that would satisfy the MIPS requirement and result in you avoiding a payment adjustment. The IA’s timeframe of 90 days is the same as the 90-day reporting option in Pick Your Pace, but you can select to do only IAs rather than Quality or Advancing Care Information.

How Are Improvement Activities Scored?

In this program, one must participate in enough activities for a minimum of 90 days to earn 40 points. All IAs are weighted either high (20 points) or medium (10 points). Participants can complete any arrangement of activities which earns 40 points. However, if a provider belongs to a practice with fewer than 15 providers or if a provider practices in a rural or health professional shortage area, then only 20 points are needed. Participants still need to complete the activities for a minimum of 90 days.

Do I report individually or as a group?

IAs can be reported by individuals or through group reporting. Some IAs (such as participation in the Consumer Assessment of Healthcare Providers and Systems Survey—Patient Safety and Practice Assessment #11) can only be done by groups. If you opt to use group reporting for one MIPS category, it must be used for the other two MIPS categories (Quality and Advancing Care Information).

If a practice is using group reporting, all members of the practice earn credit for any IA completed by any member. For example, there may be five members in the practice and if one of them completes routine medication reconciliation for 90 days (Population Management #14), then all five members get credit for this activity.

How do I start?

The focus of Improvement Activities is improving the care provided to your patients, and CMS believes that focusing on specific activities for a designated time period can stimulate this care. It is important that you first do an analysis of your practice:

• What are areas that need improvement?
• What changes would patients most appreciate?
• Are you currently doing improvement activities which would qualify for this program?

Then brainstorm what you can do. Hopefully, if you do need to start new or amend existing activities, you can implement something small which will not require a significant outlay of time, staffing or other resources. For example, are there programs offered through your local hospital system or through an insurance program which could satisfy an Improvement Activities requirement?

What do I choose?

There are 92 IAs organized into eight categories:

• Integrated Behavioral and Mental Health (BMH)
• Expanded Practice Access (EPA)
• Population Management (PM)
• Care Coordination (CC)
• Beneficiary Engagement (BE)
• Patient Safety and Practice Assessment (PSPA)
• Achieving Health Equity (AHE)
• Emergency Response and Preparedness (ERP)

The AUA has reviewed the complete list of Improvement Activities and has identified several which most urologists should be able to easily implement or adapt for their practices. These activities are highlighted in blue. However, you should review the entire list to see if there are other IAs which may be more applicable to your practice. Some practices may find that an option not selected by the AUA would be a proper fit.

Additionally, several activities are highlighted in green; these can be completed through use of the AUA’s Qualified Clinical Data Registry (QCDR), the AQUA Registry. If you are not yet a member of the AQUA Registry and wish to consider this reporting option, contact AQUA@AUAnet.org or 855-898-AQUA (2782) for more information.

Remember you must participate in whatever activities you choose for 90 consecutive days in 2017.

Key Tips

You do not need to report or submit information to CMS as part of Improvement Activities. Rather in early 2018, CMS will require you to attest to whatever action you completed in 2017. No one has details on the attestation process at this point, but the AUA will relay this information to members when it does become available.

Because there are many unknowns about this program, the AUA recommends that you document as much information as possible about the activities you complete. For example, if you are administering a patient satisfaction survey for 90 days, note in the patient charts who received one and when. If you attend an Institute for Healthcare Improvement event, save your registration and any materials (slides, handouts, etc.) which may have been distributed regarding the event. CMS always has the ability to audit your submissions; so, it is wise to have some kind of verification to prove what you have done.

Sometimes the work you will be doing will satisfy multiple Improvement Activities. You might want to consider taking advantage of this overlap.

Improvement Activity Resources

Several resources available in the IA Toolkit or links are available to provide more direction and guidance. It is important to note that each practice is unique, and in order to improve the care provided to patients, it is best to individualize what you will be doing as much as possible. The models and information here can serve as a basis for something that you will need to tweak slightly to make applicable to your practice.

While the AUA identified 36 activities (highlighted in blue) as achievable for urologists, some will be easier than others. Here are some details and resources available to help with these activities.

Note: The Quality Reporting measures listed on AUAnet.org are for the Registry option. Claim options are also available.

• IA_EPA_3 – Collection and use of patient experience and satisfaction data on access – This activity focuses on collecting feedback from your patients and then using this information to implement change in your practice. Many organizations offer patient satisfaction surveys such as Press Ganey or even the federal government through Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS. The AUA’s PMN even has such a survey in its Practice Management Resource Series. Practices can also design their own surveys focusing on questions they find more useful. The American Academy of Family Physicians offers advice about such surveys and has a model to review.
  
  After accumulating data for 90 days, the next step is reviewing it and determining how to take advantage of this resource. If all of your surveys are noting the same thing, it is either something you are doing very well or something that should be changed. Look for small steps that can make a big difference but will not greatly impact other resources. This activity will also satisfy IA_BE_13).
  
  
• IA_PM_13 – Chronic care and preventative care management for empaneled patients – There are six ways to satisfy this activity, but the AUA recommends that you do at least one of the following three (NOTE: Two of these would also satisfy Quality Reporting requirements):
  
  
  • Individualized Care Plan – You would need to either establish a care plan or update the existing care plan annually. This could be an advanced care plan or a plan specific to the urological treatment you are providing. While you probably do not need all the information which would be noted in an advanced care plan, it is good information to have in the patient’s file. Many patients already have such plans; so, it is merely a matter of obtaining it and putting a copy in the file. Doing this activity would satisfy IA_CC_ 9, IA_BE_15 (if it is documented in the electronic health record), and Quality Reporting Measure #47 Care Plan.
    
    
  • Reminders and Outreach – Are you using reminders and outreach to alert patients to services due? If so, you are completing this activity. The outreach could be whatever is easiest for your practice such as mailings, phone calls, emails, etc.
    
    
  • Medication Reconciliation – This action would also satisfy IA_PM_16 and/or Quality Reporting Measure #46 Medication Reconciliation Post-Discharge. However, unlike the Quality Reporting measure, you would not want to limit yourself to just patients who had recently been discharged from an inpatient facility. You would want to do it for every patient you see within the 90-day activity window.
    
    
• IA_PM_16 – Implementation of Medication Management Practice Improvements – While there are several wants to satisfy this activity, the AUA recommends that urologists do so through medication reviews or reconciliation. This activity can also be used for IA_PM_13 and Quality Reporting Measure #46 Medication Reconciliation Post-Discharge. However, you would not want to limit yourself to just patients who had recently been discharged from an inpatient facility. You would want to do it for every patient you see within the 90-day activity window.

• IA_CC_1 – Implementation of use of specialist reports back to referring clinicians or group to close referring loop – There are two ways to satisfy this activity and both involve documenting reports in the patient’s file (either electronic or paper). If you are referring patients to other providers, note that in the patient’s chart and make sure to document any reports or results the other provider sends you. Likewise if patients are referred to you, note that in the chart and make sure to note that you provided reports and/or results to the referring provider. This activity also satisfies IA_CC_12 and possibly IA_CC_13.

• IA_CC_2 – Implementation of improvements that contribute to more timely communication of test results. This activity requires that you contact any patient that has an abnormal test result and that you document the result and how and when you contacted the patient, which could be by mail, phone call, etc. CMS does not define “timely,” but most offices already have a working definition of this.

• IA_CC_7 – Regular training in care coordination – A practice must have “documentation of implemented regular care coordination training within practice.” However, this is very open. There are many organizations which offer care coordination such as the Agency for Healthcare Quality and Research’s free monthly webinar series entitled TeamSTEPPS. In whatever program you decide to use, at least one member of your practice would need to register (and keep validation of that) and participate in the webinar. The webinars are also archived; so, webinars can be viewed whenever it is most convenient. Your practice (or at least a quality improvement team) should discuss the content of the webinars and implement that which might be feasible. CME and other forms of accreditation are often offered for these webinars and training sessions.

• IA_CC_9 – Implementation of practices/processes for developing regular individual care plans – To complete this activity you could utilize an advanced care plan or a plan specific to the urological treatment you are providing. While you probably do not need all the information which would be noted in an advanced care plan, it is good information to have in the patient’s file. Many patients already have such plans; so, it is merely a matter of obtaining it and putting a copy in the file. Doing this activity would satisfy IA_PM_ 13, IA_BE_15 (if it is documented in the electronic health record), and Quality Reporting Measure #47 Care Plan. Additionally sharing the patient’s medical records with a beneficiary or caregiver designated in the care plan would satisfy this activity.

• IA_CC_12 – Care Coordination agreements that promote improvements in patient tracking across settings - If you are referring patients to other providers, note that in the patient’s chart (either paper or electronic) and make sure to document any reports or results the other provider sends to you. Likewise if patients are referred to you, note that in the chart and make sure to note that you sent reports and/or results to the referring provider. This activity also satisfies IA_CC_1 and possibly IA_CC_13.

• IA_CC_13 – Practice improvements for bilateral exchange of patient information. One aspect of this activity is the use of structured referral notes. Check with your electronic health record (EHR) vendor to verify the best way to includes referral notes. This activity can also be set up in such a way that it would also satisfy IA_CC_1 and IA_CC-12.

• IA_BE_6 – Collection and follow-up on patient experience and satisfaction data on beneficiary engagement – If you are using any kind of patient survey (as discussed in IA_EPA_3 and IA_BE_13), you can satisfy this activity by taking it to the next level. For example, your practice could follow up with patients to address any concerns they might have or your practice could use this information to design an improvement plan. The plan does not need to be implemented at this stage, but there must be concrete evidence that you have administered a patient survey and then drafted improvements based on the survey’s results.

• IA_BE_13 – Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms - This activity focuses on collection feedback from your patients and then using information to implement change in your practice. Many organizations offer patient satisfaction surveys such as Press Ganey or even the federal government through Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS. The AUA’s PMN even has such a survey in its Practice Management Resource Series. Practices can also design their own surveys focusing on questions they find more useful. The American Academy of Family Physicians offers advice about such surveys and has a model to review.
  
  After accumulating data for 90 days, the next step is reviewing it and determining how to take advantage of this resource. If all of your surveys are noting the same thing, it is either something you are doing very well or something that should be changed. Look for small steps that can make a big difference but will not greatly impact other resources. This activity will also satisfy IA_EPA_3.

• IA_BE_15 – Engagement of patients, family and caregivers in developing a plan of care - To complete this activity you could utilize an advanced care plan or a plan specific to the urological treatment you are providing. While you probably do not need all the information which would be noted in an advanced care plan, it is good information to have in the patient’s file. Many patients already have such plans; so, it is merely a matter of obtaining it and putting a copy in the file. In order to satisfy this activity, you must produce a report from your electronic health record showing the plan of care and engagement/inclusion of the patient, family, and/or caregivers. Doing this activity would satisfy IA_PM_ 13, IA_CC_9, and Quality Reporting Measure #47 Care Plan.

• IA_BE_21 – Improved practices that disseminate appropriate self-management materials – The Urology Care Foundation (the official foundation of the AUA) has created self-management materials on numerous urologic conditions which can be provided to patients. To satisfy this activity, you must document in the patient’s record what materials distributed as well as any accompany instructions or results.

• IA_PSPA_3 – Participate in Institute for Healthcare Improvement (IHI) training/forum event; National Academy of Medicine, AHRQ Team STEPPS or other similar activity – Many national organizations, including the AUA, offer seminars and events focused on quality improvement and patient safety, and participating in one (either in person or online and some free of charge) would satisfy this activity. The AUA annually offers the Quality Improvement Summit, which will be offered on Saturday, October 21, 2017. Check the websites of other organizations (such as ihi.org, nam.edu, or ahrq.gov/teamstepps) for their offerings throughout the year.

• IA_PSPA_4 – Administration of the AHRQ Survey of Patient Safety Culture – All employees of the practice would need to complete this survey and results must be submitted to AHRQ. AHRQ provides a user’s guide as well as the form to help with its administration. At this point, CMS does not require any analysis of the results or follow up on the survey. So, simply completing and submitting would be an inexpensive and quick way to complete an activity.

• IA_PSPA_8 – Use of patient safety tools – The surgical risk calculator, such as the one available through the American College of Surgeons (ASC), is a widely used patient safety tool in urology. If you already use this or plan to start, document this act in a patient’s chart when appropriate in order to satisfy this activity. The ASC surgical risk calculator is also available on the AUA Guidelines app.

• IA_PSPA_9 – Completion of the AMA STEPS Forward program – The STEPS Forward program is an online initiative geared at improving practice efficiency as well as improving care and the patient experience. This tool can be used at your convenience and allows you to customize your educational experience by focusing on both clinical and practical modules. CME is available for some modules. Start by watching the overview video before you begin.

• Participation in a Qualified Clinical Data Registry (QCDR) – Many activities may be achieved just by participating in a QCDR. The AUA offers the AQUA Registry, which is a CMS-approved QCDR. AQUA can also be used to complete the Quality reporting program as well as satisfy some aspects of Advancing Care Initiative. For more information, contact AQUA@AUAnet.org or 855-898-AQUA (2782).

Questions?

The AUA is here to help. Contact AUA staff at Quality@AUAnet.org or 410-689-3925 with your IA questions or any issues related to MIPS reporting.

CMS also has online resources available to assist providers with MIPS. The QPP Help Desk can answer questions at 866-288-8292 or qpp@cms.hhs.gov.

Disclaimer: The AUA enourages practices to download and review CMS’ improvement activity (IA) data validation requirements (https://qpp.cms.gov/measures/ia). Providers should maintain documentation supporting the compilation of each activity, in the event of a future CMS audit. Additionally, the AUA and AQUA Registry cannot guarantee a positive/negative payment adjustment at any time.