AUA MIPS Reporting Webinar - January 8, 2019: Changes for Year 3 (2019) of the Quality Payment Program and MIPS Data Submission for Year 2 (2018)
Along with the AUA, CMS subject matter specialists Barbara J. Connors, DO, MPH and Patrick M. Hamilton, MPA highlight some of the 2019 changes to the MIPS program as well explain how to submit data to CMS as required by MIPS. In addition to these informative presentations, a series of AUA member questions were answered.
AUA 2018 MIPS Reporting Webinar - April 24, 2018
Learn more about 2018 Merit-based Incentive Payment System (MIPS) reporting through a webinar hosted by the AUA on April 24, 2018. Centers for Medicare & Medicaid Services (CMS) MIPS experts Dr. Barbara Connors and Patrick Hamilton explained the four reporting components (Quality, Improvement Activities, Advancing Care Information/Promoting Interoperability, and Cost) as well as noting who might qualify for exemptions, how to earn bonus points, and much more.
Following their presentations, Dr. Connors and Mr. Hamilton participated in a question and answer session with AUA members.Due to technical problems, we are not able to include that part of the webinar presentation. However, we are able to provide the content here:
In 2018, are we reporting ACI or ACI transition measures?
Mr. Hamilton: So, what that means, if you are not familiar, is that ACI is what used to be Meaningful Use. Transition measures are measures that we continue to allow in the program in 2018 for clinicians and practices that have not upgraded the version of their certification. So, if you have any history with the Meaningful Use program, we had certification when the program began in 2011, which means in 2011 all of your systems had to be certified to do the activities that were necessary for Stage 1. The next certification came along in 2014 which allowed the systems to do more things, and then the current certification came about in 2015. We originally said that 2018 was the year that everyone had to be on the 2015 edition of certification, but for at least 2018, we are allowing either 2014 and/or 2015 certification. Because there are two certifications, there are two sets of measures in the Advancing Care Information. The transition measures refers to the measures that we are continuing to allow practices to submit if they are using the 2014 or combination of the 2014/2015 certification. I do not believe that any decision has been made in terms of what will be required in 2019. So, I have not seen or heard anything that says one way or the other that everyone has to be on the 2015 certification next year. I can tell you that once that line has been crossed, once we say "all right everyone up to 2015," those transition measures most likely will go away. I don't know that it will happen in 2019. We have referenced this throughout our presentation numerous times; there is a new initiative across all of Medicare to reduce burden, and one of the reasons why we continue to allow both certifications, the old and the new, was to reduce the burden on the part of the clinician and the practice to have to spend the money that is needed to upgrade to 2015 certification. That's kind of a long about way of saying we don't know yet, but that is kind of the background of transition measures and why we are continuing to allow both sets.
Dr. Connors: One thing I want to bring up about the transition measures, the transition objectives and measures can be reported using both systems (certified to 2014 and certified to 2015) OR a system certified to 2014 or a system certified to 2015. They can still report those transition measures if they have the 2015.
We received a hardship for 2017 reporting. Now I do not know what I am supposed to do for 2018. Can you offer any advice?
Mr. Hamilton: For hardship exemptions, there are different types of exemptions or exclusions in the program. When I was talking about the exclusion if you don't meet the patient or the billing criteria, then you could be excluded from MIPS in general. But, within certain parts of MIPS, and this is probably for the Advancing Care Information (the electronic health records portion of the program), there are certain caveats you can meet in order to be exempted just from that part of the program. You still have to do Quality. You still have to do Improvement Activities. But, there are certain situations for which you can qualify for an exemption just for Advancing Care Information. But I can tell you, an individual exemption is only for that year. So, if you were exempt in 2017, you either have to do the performance in 2018 or you would have to submit another application to see if you would be exempt in for 2018. The exemptions do not care over from year to year.
Does 200 patients mean 200 different patients-meaning a beneficiary who is seen three times is counted as one or three?
Mr. Hamilton: Two hundred individual Part B Medicare beneficiaries that have traditional fee-for-service Medicare. So a patient that you see three times is counted once. Medicare Advantage patients do not count.
How do we know what certification we are on?
Mr. Hamilton: Most likely you are working with a vendor. Most people go through a vendor in order to purchase their system. My first call would be to your vendor. If you have an idea of when you purchased your system, that may be a clue. It is either 2014 or 2015; no one is using 2011. It is either/or. Some of the questions you might want to ask is if you were still prepping for Meaningful Use back in 2015/2016. The 2014 edition was developed so that practices could meet Stage Two requirements, which started for some people in 2014. The 2015 certification was developed for Stage Three. If that jogs your memory that you were ready to do Stage Three, you probably have the 2015 edition. If you were still muddling around in Stage Two, you likely have the 2014 edition, but you should contact your vendor. There is also something called CHPL. Google ONC, which is the Office of the National Coordinator which is the entity within HHS which oversaw the certification and all the technical components of the program. They have something called the CHPL. If you have a certification number, I think there is still some type of portal that you can put that number in and it will tell. Probably easiest just to call your vendor, though.
We have heard that there are changes in blood pressure normal. Is 100/80 now normal? We need to know this for MIPS.
Mr. Hamilton: I am not a clinician; so, I'm not able to discuss that. All I know is that I also heard that there were also changes to blood pressure. I cannot give you an answer to that because that is really beyond the MIPS program. What we can do is that we can see if there has been an update to the specifications for any of the measures that touch on normal blood pressure, and we can see, at least from a QPP standpoint, if those updates have been made. I don't know what the process is. If there are entities outside of the agency or outside of the government that decide that 120/80 or 130/70 or whatever it is-that's the new normal. I don't know how quickly we adapt our measures and other stuff that we do with that here in the agency. That is something that we will have to look into.
Further data: The only quality measure data on the website is for the 2017 program. Four of the 5 measures reference a BP of 140/90. No references to 130/80 have been attached to the quality measures for 2018 yet.
Are Quality and Promoting Interoperability two different things? If so, what is considered to be Promoting Interoperability?
Mr. Hamilton: So, that is why the slide deck cannot be shared because I believe the version that I pulled is a draft. We are in the process of renaming Advancing Care Information. Advancing Care Information, hopefully you know by now, is what used to be Meaningful Use. We are still trying to test out different names for it. And the last that I have heard is that we are toying with the idea of using interoperability to describe the EHR component of the program. So, they are two different performance categories. Quality is the quality measures. Think similar to the activities you did under PQRS. The interoperability thing is the EHR component.
What kind of risk adjustment is used for the Cost measures?
Dr. Connors: There are two cost measures now: Medicare Spending per Beneficiary and Total per Capita Cost. Medicare Spending per Beneficiary includes the cost of care to that patient, from three days prior to hospitalization out to thirty days. The Total per Capita Cost is the entire cost for one year, and in both categories those are the patients that are attributed to you-another huge reason to look in July at the feedback report because the attribution is there. You might see that there are patients there that should not have been attributed to you; yet you are responsible for the total cost of that patient's care. Now we have information on the QPP portal about the risk adjustment for patients. It really has to do with the MCC levels. We also know that those patients have the most chronic conditions in particular those with conditions greater than six or more. We are working with risk adjustment for that as well. We do have information now on our website. I think the coding is really important in terms of all of the issues around all of the patient's clinical problems. We are not at the point yet where we are including the social determinants of health as risk factors regarding the cost of care in the Cost category. However, there was another question regarding the voluntary modifiers that are not currently a condition of payment. We are using the HCPCs modifiers reporting for those codes which are the relationship codes (clinician/patient relationship codes) introduced early on in 2016. Then we received some feedback. Then we proposed in 2017 particular patient relationship codes. They are not mature enough to be used; so, we are using the HCPCs codes, and we do have information on our site regarding that as well. It is voluntary at this point, but again we are testing these codes. They will be considered in future years toward the risk adjustment and toward the total cost of care. So, let's say you have a patient who for some reason has significant problems in that particular year. As a urologist, you had more billables and the patient is attributed to you. That relationship code is really critical because it identifies that you are caring for that patient during an acute episode as a specialist. If there are any further questions, you can send an email and I can send some information out.
We do not have an EHR. We have three surgeons in our practice. If we meet group criteria, what would we have to do to be neutral? Fifteen points in Quality and Improvement Activities? Cost could take points away. Is that correct?
Mr. Hamilton: There are ways for 2018 that the score that has to be met is 15. There may be ways for a group to submit full quality measures and meet full Improvement Activities if you are looking to just surpass a score of 15 to do so. I would have to go back because I know in a previous slide deck for 2018 we do talk about some scenarios or ways that one can submit less than all of the data. I would have to see if any of those scenarios allow for not doing any Advancing Care Information activities.
Dr. Connors: They have four options: They can report all the required Improvement Activities. Submit six quality measures that meet the data completeness criteria. That is the critical piece. The other two involve the Advancing Care Information. I will not read those points. So, it is either/or as Patrick referenced: the Improvement Activities or the six quality measures. Most important, make sure you meet the data completeness criteria; that is sixty percent for each measure.
Dr. Connors: The improvement activities OR the six quality measures that meet the completeness in order to receive the 15 points.
Will there again be an exclusion from the Health Information Exchange objective?
Mr. Hamilton: I believe that this exemption carried over for 2018.
What is the benefit of using a new Quality measure if the benchmark is only 3 points?
Dr. Connors: One would only receive three points if there is no benchmark or if you are submitting incomplete data, for example, and you're a smaller group, but that is an aside. If enough eligible clinicians do submit that Quality measure, we may have a benchmark after the submission period is closed. As I mentioned earlier your score could change. That is where we are going to see most of the changes. Those measures that were submitted that don't have a benchmark that now have a benchmark. However, if you submitted a Quality measure without a benchmark, you knew you were going to receive a score of three; we are not going to drop your score for a quality measure that now has a benchmark.
We will be adding a new provider this summer. How do I report for a provider that joined my practice midyear?
Dr. Connors: Well, is the practice reporting as a group or individual? That is really the question.
Mr. Hamilton: And, does the provider when coming to the new group have access to information from earlier?
Since more information is needed, this questions should be directed to the QPP Help Desk.
Is there a bonus for using a QCDR over any other type of reporting mechanism?
Mr. Hamilton: There isn't a bonus, but it is a submission mechanism for certain situations. I don't believe there are QCDR bonus points available.
The instructions say I must report an outcome measure "if available." What does "if available" mean? There are general outcome measures on the list of Quality measures and it seems that most providers would be able to use one of these if necessary. As a urologist do I have to report one of these or could I do a high priority measure?
Mr. Hamilton: That is where we get to the idea of validation. What we do is look at the types of services and number of beneficiaries that are receiving that service for certain providers and practices. There is a determination made as to whether or not an outcome measure would pertain to the types of services that are generally being administered by that practitioner.
We have a two-man group. One doctor plans to participate in MIPS; the other does not. Will both doctors be penalized or just the one not reporting?
Mr. Hamilton: If they are reporting as individuals, the one who is reporting will be fine. The one not reporting will be subject to payment adjustments. One thing that we didn't talk about is that when we were talking about the scale from zero to 100, if you do absolutely nothing and you get a zero, you get the maximum negative adjustment. So in 2020 (that's for 2018 participation), you get five percent. So, providers and clinicians, who make the determination that they can live with the five percent cut, may decide they do not want to participate for various reasons (we hope that they won't decide that). The only thing that they would have to look into is that if they are going to report as a group, whether or not the doctor who is reporting will be able to carry the weight of the one who isn't. But, the two-man group, my guess is that they would just report as individuals.
If you submit all of your data through a registry, but use your EHR to get your data to report for the ACI portion, do you still get the 10 percent bonus points?
Mr. Hamilton: I am assuming you are talking about the end-to-end reporting.
Dr. Connors: I want to say yes, but I would feel better about going back and checking if they are using a registry. I believe it is a yes. Hopefully the registry would be reporting their EHR information, but I would have to go back and check on that.
Further data: Any submission pathway that involves manual abstraction and re-entry of data elements that are captured and managed using certified health IT is not end-to-end electronic quality reporting is not consistent with the goal of bonus.
How would Cost measures be used for urologists? Who may have attributed patients?
Dr. Connors: It really depends on the kinds of patients a urologist is caring for. Some patients may only have a urologic problem for that year. So, let's look at the patient with prostate cancer. Without any other underlying medical conditions and not seeing their PCP routinely, that could be a patient that is attributed to the urologist.
I have been using claims reporting. Will this option be available in future years?
Mr. Hamilton: That is something where the determination will be made on a year by year basis. We have not heard anything that the claims option is going away. My guess is that with the whole burden reduction initiative that is going on, we know that claims reporting is still a way that a lot of clinicians prefer to report. So, I would think that is not going away in the near future. However, the caveat is that, again, you have to pay attention to rulemaking. We usually come out with our proposed rule for the fee schedule for the following year sometime in the summertime. That is going to give you your first idea of what is being thought about for the program for the following year. My guess would be that it is not going way anytime soon. But, again, that is my opinion.
I plan to report with a clinical registry. I understand that I now have to report on more than just my Medicare Part B patients. Whom do I include such as Medicare, Medicaid, Medicare Advantage, other insurers?
Dr. Connors: Is the registry asking that all the patients be included?
Moderator: It is someone planning to use a registry.
Dr. Connors: Is it the AUA registry?
Moderator: No, it is a clinical registry not a QCDR.
Dr. Connors: In that case I would include all the patients that are applicable to the measure they are reporting.
Moderator: So, that would be everyone?
Dr. Connors: Well they are not reporting on 100 percent of patients because they are not reporting measures for a patient. They are choosing measures that apply to specific categories.
Are urologists able to use the Web Interface? It seems pretty primary care focused.
Mr. Hamilton: The Web Interface is solely for groups of 25 or more eligible clinicians. So, it is only for groups and groups of 25 or more. You have to be able to report on what I believe are 18 measures that are in the interface. If you can't report on all 18 measures, then you would have to select another reporting mechanism.
What is there are not six measures I can report?
Mr. Hamilton: A couple of things. If there are truly not six measures, you report the number of measures that you can, and I mentioned earlier about a validation process that, based on the claims that you are providing, CMS determines if other measures could have been chosen. There are also specialty measure sets, and I believe that urology is one of them if I'm not mistaken. If you go on to QPP.CMS.gov and click on Quality, you can pull up the specialty measure sets. What you can do even if there are not six in a given measure set, let's say for example (I don't have it in front of me) that urology only has four, then because you are a urology specialist that you can chose that urology measure set. Even though you are choosing just four, you will still get full credit for selecting that measure set. The way the calculation is done for the Quality score, if you are choosing less than six, we make adjustments so that you are not getting zeros for those other two measures that you are not reporting for. There are adjustments made in the calculations. I would definitely check the urology measure set. I'm pretty sure there is a urology specialty measure set on the QPP website.
Moderator: We do have a urology measure set, and I believe there are twelve measures in there. So, what happens if they cannot report six from that?
Dr. Connors: The measures in the urology measure set are pretty broad. I would find it hard to believe that a urologist would not be able to report these things: Person and caregiver centered experience, community and population health, communication and care coordination, effective clinical care for a diabetic, several for prostate cancer, urinary incontinence. Unless it is a super, super urological specialist I would think they would be able to meet these measures.