Choosing quality measures and quality improvement activities for the small practice

1. Quality Payment Program Small Underserved Rural Support (QPP SURS) Lan webinar September 12, 11:00-12:00 ET; September 14, 3:30-4:40 ET Choosing quality measures and quality improvement activities for the small practice

2. Choosing Quality measures & Improvement activities Please mute your computer speakers to avoid audio feedback Dial into the call by using the call-in information on the screen For Operator assistance, dial *0 To ask a question, enter your inquiry in the chat box, or press *1 to enter the queue on the phone HOUSEKEEPING ANNOUNCEMENTS

3. Choosing Quality measures & Improvement activities What is your role? 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 POLLING QUESTION

4. Choosing Quality measures & Improvement activities What describes your practices readiness for submitting quality measures? We are not currently collecting or monitoring any quality measures We are collecting a few measures but need to collect more to meet MIPS requirements We are collecting enough quality measures for MIPS We are collecting more quality measures than MIPS requires and are deciding which ones to report POLLING QUESTION

5. Choosing Quality measures & Improvement activities Brenda Gentles, RN, BS, MS Division of ESRD, Population & Community Health Centers for Medicare & Medicaid Services QPP- SURS Central Support Contractor COR Cms welcome

6. Choosing Quality measures & Improvement activities David Smith, MBA, HIT Project Manager, HealthInsight, Oregon Amasa Baldwin, MHSA, QI Consultant, TMF Health Quality Institute Paul Babineau, Clinical Manager, Eye & LASIK Center Aaron Hubbard, MHCA, Project Manager, HealthInsight, Nevada Bruce Spurlock, MD President & CEO, Cynosure Health

7. Choosing Quality measures & Improvement activities Event Focus: • Practical advice for choosing quality measures and quality improvement activities • Focus is on what works best for SMALL group practices—requirements mentioned are for practices of fewer than 15 participants Begin with very quick overview: • Overview the WHY, WHO, WHEN, HOW & WHERE • Major focus: WHAT Setting the stage

8. Choosing Quality measures & Improvement activities Aligning payments with high quality & efficient care is in the best interest of patients and the healthcare system Finances, public reputation & preparing for the future make MIPS important even if financial impact is not large WHY mips matters

9. Choosing Quality measures & Improvement activities All clinicians and practices that meet minimum Medicare volume thresholds Groups, individuals and virtual groups Clinicians 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) Who mips affects Check your eligibility at: QPP.CMS.GOV

10. Choosing Quality measures & Improvement activities Choose to submit through a qualified registry, a QCDR, an EHR or using claims data (pick one) Nothing due to CMS until March 31, 2018 but submission can begin January 1, 2018 and starting sooner than March is recommended Deadlines for particular EHR or Registry vendors may be earlier so it’s important to check BUT: Doing the work to generate the information you’ll need to submit should be happening now and must begin by Oct. 1, 2017 When, How and where to submit MIPS information

11. Choosing Quality measures & Improvement activities 6 quality measures (one outcome) for full participation No cost information required What must be submitted? • 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 participation

12. Choosing Quality measures & Improvement activities What’s the bare minimum I need to do in order to avoid a penalty Question:

13. Choosing Quality measures & Improvement activities One quality measure on one patient, one time (sometimes called “test method/test pace) Submit using your EHR, a qualified registry, QCDR, or using claims data Doing more than the bare minimum is better: • 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 Avoiding the penalty is easy

14. Choosing Quality measures & Improvement activities How do we pick the best quality measures to collect and report? Question:

15. Choosing Quality measures & Improvement activities Use the measure selector on the QPP website to identify options best suited for your patients Know your options • Measure selector available at:https://qpp.cms.gov/mips/quality-measures • Other non-MIPS measures can also be used and are listed on the QPP website

16. Choosing Quality measures & Improvement activities Use the Quality and Resource Use Reports to identify other options (2015 is available, 2016 available soon. • Info on how to obtain reports available at: (https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeedbackprogram/obtain-2013-qrur.html Use measures reported in PQRS: (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html) Know your options

17. Choosing Quality measures & Improvement activities • Focus on which are most important for your patients • Insure those measures are available with the data submission method you plan to use • Build off measures you’re already collecting & monitoring • Get buy-in from clinicians and other key people in your practices Choose measures strategically

18. Choosing Quality measures & Improvement activities • CMS picks the best measures out of those you report • Reference benchmarking database to see how you compare (https://qpp.cms.gov/about/resource-library document is called 2017 quality benchmarks) • Use MIPS score calculator to get a preliminary score (many calculators available: https://www.stratishealth.org/providers/data/MIPS-Estimator/ http://www.healthcarefornewengland.org/qin-telligence/scoring-mips-quality-category/ Consider your mips score

19. Choosing Quality measures & Improvement activities What common mistakes do you see small practices making when they choose quality measures and how can these be avoided? Question:

20. Choosing Quality measures & Improvement activities Selecting topped-out measures If using QCDR measures, failing to confirm available benchmarks and that more than 20 will submit Failing to monitor your numbers and following up with clinicians to address misconceptions or data entry errors causing low scores Not looking for help available from your Direct Support Organization, QIN, medical associations or other groups Common mistakes to avoid

21. Choosing Quality measures & Improvement activities How would you describe your practice’s current involvement in quality improvement activities? We regularly participate in QI activities led by external partners like professional societies or medical associations that involve data collection and reporting We participate in some QI activities led by external partners like professional societies or medical associations but don’t collect or report data for them We regularly participate in internal quality improvement activities but not external ones We occasionally do internal quality improvement activities but aren’t that experienced We do our best to take care of our patients but don’t have time or resources for quality improvement projects POLLING QUESTION

22. Choosing Quality measures & Improvement activities What do I have to do to meet the Quality Improvement requirements for MIPS? Question:

23. Choosing Quality measures & Improvement activities 2017 Requirements: • Small group practices only report 1 high-weight or 2 medium-weight QI activities (see QPP website for list of activities meeting requirements) • You must attest to doing QI for 90+ days but do not have to show improvement 2018 Added Requirement: Begin showing improvement Quality improvement activity Requirements for small group practices

24. Choosing Quality measures & Improvement activities QI options available at: https://qpp.cms.gov/mips/improvement-activities Filter by weighting & 1 or more of 8 improvement areas Drill down on a selected QI activity to get more information about it

25. Choosing Quality measures & Improvement activities Considering Quality improvement activities Consider what’s best for your patients What has buy-in from your staff What is doable within your resources Consider the impact on your quality measures and vice versa Take into account advice from your SURS Direct Support Organization, professional societies, your QIN and others

26. Choosing Quality measures & Improvement activities How do I report my quality improvement activities once I perform them Question:

27. Choosing Quality measures & Improvement activities Reporting Quality Improvement Activities Most EHR vendors and registries will provide options for reporting QI activities but verify this before choosing them Review and comply with CMS requirements for choosing and documenting quality improvement activities (see QPP website) Get advice from your Direct Support Organization or QIN on the data submission option that is best for you Other submission processes may be developed by CMS

28. Choosing Quality measures & Improvement activities What common mistakes do you see small practices making when they choose quality improvement activities and how can these be avoided? Question:

29. Choosing Quality measures & Improvement activities Not reviewing data validation criteria Failing to collect and keep required documentation for quality improvement activities Failing to pick quality improvement activities that are aligned with practice priorities and that matter to your patients and practice Common mistakes to avoid

30. Choosing Quality measures & Improvement activities 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.html) Contact the Quality Program at: QPP@cms.hhs.gov or call 1-866-288-8292 Small Underserved Rural Support Direct Support Organizations • Contact information on available at: https://qpp.cms.gov/docs/QPP_Support_for_Small_Practices.pdf • Available websites of each Direct Support Organization • Types 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 • Other national events about Quality Payment Program Other national webinars focused on small practices Sources of assistance from cms

31. Choosing Quality measures & Improvement activities In the next four 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 POLLING QUESTION

32. Choosing Quality measures & Improvement activities If you are not planning to participate this first year, please share what you believe to be your challenge in successfully participating? Final POLLING QUESTION

33. Choosing Quality measures & Improvement activities • Links to the recording of the event available at: https://qppsurs.wordpress.com/resources/ • Future webinar topics and timeframe: • Oct. 17 at 3:30 pm ET and Oct. 19 at 11:00am ET; How Small Group Practices Can Maximize their MIPS Advancing Care Information Score • Nov. & Dec. events also planned • Please provide feedback on this event: https://goo.gl/forms/jlXg6nasduq9KzPF3 Wrap-up activities The original source of some of the materials contained in these slides is:https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Merit-based-Incentive-Payment-System-MIPS-Overview-slides.pdf. This document and others on the QPP.CMS.GOV website provides 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.