MACRA Quality Payment Program

MACRA Quality Payment Program MIPS Quality Component Jill Sage | Quality Affairs Manager DIVISION OF ADVOCACY AND HEALTH POLICY MIPS Quality Component Overview of the quality data submission requirement Reporting options and quality measures Scoring the quality component Tips on how to be successful Quality Payment Program MIPS Quality Component MIPS: 2019 Payment Adjustment* *CY 2019 payment adjustments based on CY 2017 performance Qualit

y ACI IA Cost (25%) (15%) (0%) (60%) Quality Payment Program MIPS Quality Component Final Score MIPS: Quality Data Submission Criteria MIPS submission mechanisms: Qualified Clinical Data Registry (QCDR), Qualified Registry,

EHR, Claims Report a minimum of six measures, including: Composit e One outcome measure OR Performa One high-priority measure if an outcome measure is not nce available Score (CPS) Report on 50 percent of all-payer patients (50 percent of Medicare patients for claims reporting) Quality Payment Program MIPS Quality Component Pick Your Pace in MIPS: Quality Performance Category Do Nothing Test Pace

Partial Participatio n Full Participatio n Do nothing Get a 4 percent penalty Report one quality measure for at least one patient Avoid 4 percent penalty Report six quality measures for a minimum of 90 days, including one outcome or one high-priority

measure May earn a positive adjustment Report six quality measures for a full year, including one outcome or one high-priority measure May earn a positive adjustment Quality Payment Program MIPS Quality Component Important to Note Positive adjustments are based on performance, not the amount of information or length of time providers reported

Quality Payment Program MIPS Quality Component MIPS: Quality Measures Surgeons can select six measures from: List of approximately 300 MIPS quality measures Specialty-specific set of measures Qualified Clinical Data Registry (non-MIPS measures) Composit e for Groups can continue to report via the Centers Performa Medicaid & Medicare Services (CMS) Web interface or nce Consumer Assessment of Healthcare Providers and Score Systems (CAHPS) for MIPS (CPS)

Quality Payment Program MIPS Quality Component Specialty-Specific Measure Set Example General Surgery Perioperative Care: Selection of Prophylactic AntibioticFirst OR Second Generation Cephalasporin Anastomotic Leak Intervention Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) Unplanned Reoperation within the 30-Day Postoperative Period Documentation of Current Medications in the Medical Record Composit e within 30 Days Unplanned Hospital Readmission of Principal Procedure

Performa Surgical Site Infection (SSI) nce Score Patient-Centered Surgical Risk Assessment and (CPS) Communication Preventive Care and Screening: Tobacco Use Screening and Cessation Intervention Closing the Referral Loop: Receipt of Specialist Report Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Tobacco Use and Help with Quitting among Adolescents Care Plan Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan Quality Payment Program MIPS Quality Component

MIPS: ACS Registries for 2017 MIPS Reporting The ACS has two registries that can be used for reporting MIPS for 2017: The Surgeon Specific Registry (SSR) and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Composit Program (MBSAQIP) Offers two submission mechanisms: QCDR (non-MIPS measures) Traditional registry (MIPS measures) Quality Payment Program MIPS Quality Component e Performa nce Score Offers the QCDR(CPS) (nonMIPS measures)

submission mechanism MIPS: Scoring for Quality Three to 10 points on each quality measure based on performance against benchmarks Bonus points available: Composit Two bonus points for each additional outcome or patient e additional experience measure; one bonus point for each Performa high-priority measure nce One point for end-to-end electronic reportingScore (CPS) Failure to submit data will result in a score of zero Quality Payment Program MIPS Quality Component MIPS: Tips for Success in Quality

Report on at least six measures, with as many outcome and high-priority measures as you can Report for a time period that will allow you to have reliable data or at least meet the minimum case volume Review your PQRS Feedback Reports Utilize ACS resources, including ACS registries available for reporting MIPS Quality Payment Program MIPS Quality Component