- It’s good to have options when it comes to the clothes we wear, cars we drive, and things we do. But having too many options when it comes to quality reporting under MACRA’s Merit-Based Incentive Payment System (MIPS) may prove to be too much for providers and their EHR vendors, stated Ida Mantashi, CMHP, the chair of the Quality Measurement Workgroup at the HIMSS Electronic Health Record Association.
Flexibility is a top priority for CMS as the federal agency rolls out its latest approach to linking Medicare reimbursement to care quality.
The federal agency shifted away from standard data sets for quality reporting like under the Hospital Value-Based Purchasing Program and the Value-Based Payment Modifier. Under MIPS, eligible clinicians can select six out of 271 quality measures to earn points under the quality category as long as at least one measure is considered outcomes-based.
In addition, eligible clinicians have several options for reporting quality data to MIPS. CMS will accept quality data from individual clinicians if it is submitted via Qualified Clinical Data Registries (QCDR), approved registries, EHR systems, and administrative claims.
For eligible clinicians electing to report as a group, CMS will also allow data from a CMS-run Web Interface and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey.
Eligible clinicians may feel overwhelmed as they choose not only which MIPS measures to report on, but how to report them. They can elect to submit information to MIPS through just one mechanism, such as their EHR, or they can attest to MIPS via multiple quality reporting mechanisms and CMS will use the best score.
A recently proposed rule for MACRA implementation in 2018 would also extend MIPS quality reporting flexibilities for another year.
“Providers are going to facing challenges because they are putting so many options in front of them,” said Mantashi, who also acts as a Senior Project Manager at Modernizing Medicine. “It seems very nice, but it’s going to be more difficult for them to understand which option is the best option for them.”
But providers are not the only healthcare stakeholders feeling anxiety from a wide range of MIPS quality reporting options, she stated. With eligible clinicians using a patchwork of reporting mechanisms to attest to MIPS, EHR vendors may find it harder to act as a partner for their providers as they strive for quality improvement.
“It’s very challenging for the EHR vendors to do the calculation when we will not have all the information,” she said. “Then, we have to do a lot of connectivity with the other registry to make sure that they can collect the required information.”
Mantashi explained that EHR vendors normally make measure sets available to providers so they can see how quality performance is tracked through dashboards.
However, EHR vendors are scratching their heads as they try to devise methods for displaying provider performance on quality measures when clinicians can choose from different mechanisms.
While MIPS attestation flexibilities create challenges for EHR vendors, providers should still turn to their systems for advice on which MIPS quality measures to select.
“Now some of the EHRs and the dashboards show which measures the providers are doing better on,” Mantashi advised. “We do recommend them to stay with that selection. Select the top six that they’re doing much better and don’t forget about outcome measures and high-priority ones.”
Selecting measures already supported by an EHR system or dashboard will help eligible clinicians to predict their payment adjustments based on their performance as well as refocus their attention on patient care, rather than quality reporting.
“It’s important to choose the measures that they use is in their everyday workflow, so they don’t have to change their workflow or they don’t have to get away from their everyday practice just to meet some of the more complex measures,” she stated.
CMS has jumpstarted this process for eligible clinicians by creating specialty measure sets. To help clinicians understand which of the quality measures apply to their specific practice or organization, the federal agency established measure sets for 31 provider types, ranging from general practice providers and pediatricians to radiation oncologists and dermatologists.
The specialty measure sets serve as a guide for eligible clinicians faced with many quality reporting options and Mantashi highly suggested that clinicians take advantage of the sets. The measures should align with established provider workflows.
Specialty designations should also help eligible clinicians choose an appropriate MIPS reporting mechanism, she added.
“What is important is the specialty that they are in, which will dictate which measure to use,” she said. “Registry measures are very much focused on the specialty and if they are in a specialty business, we do highly recommend using either QCDRs or a specialty registry because they’ve been built specifically for the specialties.”
On the other hand, eligible clinicians in hospitals or who practice general medicine may want to consider electronic clinical quality measures (eCQMs), which are reported through their EHR systems. CMS collaborates with healthcare stakeholders to establish standard eCQMs that can be used to measure care quality using data from EHRs and other health IT systems.
The federal agency has included some eCQMs as part of the MIPS program.
Since the quality measures are standardized by a governing agency, many EHR vendors and health IT companies have included eCQMs in their products.
“eCQMs don’t have enough measures for specialties, so unfortunately, it’s not a big hit for our clients,” Mantashi elaborated. “But if you belong to a hospital or you’re practicing in general medication, eCQMs are a very easy way to achieve reporting, because the eCQMs are part of and still is part of a certification process, so all the vendors who are actually certified should carry a good handful of the eCQM measures.”
While providers should choose specialty-specific measures and those that already fit into their workflows, she warned eligible clinicians to beware of topped out measures.
“The topped-out measures are the measures on which providers have been doing really well, meaning the providers have been scoring very high with those,” she stated. “We know those are going to be retired soon, so don’t count on those too much.”
The same warning should be applied to brand-new measures devised for MIPS.
“Second, don’t choose the brand-new measures because there’s no benchmark for those measures and the maximum they can score right now is three,” she added.
Reporting on MIPS quality measures with a benchmark is key to maximizing performance points. Clinicians can earn over three points for measures scored against a benchmark. But measures without that target are only worth a maximum of three points in 2017 and possibly in 2018 if the proposed MACRA implementation rule for that year is finalized.
MIPS cost and virtual group flexibilities create obstacles for providers and vendors
Quality reporting options are not the only issues providers and vendors are facing with MIPS flexibilities. Mantashi explained that the transition CMS created to introduce the MIPS cost category may also hinder provider performance and EHR vendor support.
CMS temporarily suspended the MIPS cost category in 2017 to give providers additional time to digest the performance component and prepare their practices for cost-based measures, explained Reena Duseja, MD, CMS Director of the Division of Quality Measurement, at HIMSS17.
The federal agency intended to up the MIPS cost category’s weight to 10 percent in 2018. However, the recently proposed rule may uphold the suspension and then increase the weight of the category to 30 percent in 2019 as originally planned.
“The concern here is that we don’t really know how the providers are going to be scored,” Mantashi explained.
Providers may face challenges with understanding cost-based measures and MIPS scoring and health IT vendors will be equally in the dark.
“We don’t know how to help them to improve that score when all of the sudden it becomes 30 percent, which is a very large portion of their score in 2019,” she said.
Mantashi also foresees virtual group implementation to be a significant hurdle for health IT and EHR vendors.
CMS designed virtual groups to allow independent providers or those practicing in organizations with 10 or fewer eligible clinicians to band together to report on all four MIPS categories. Under the virtual group, clinicians can leverage patient volume and technological capabilities of providers in similar organizations to maximize their MIPS performance score.
However, health IT and EHR vendors will have to find a way to manage data for disparate providers who are connected by a virtual group.
“The virtual group is introducing this new program that brings multiple providers from different teams under the same umbrella or under the same group,” Mantashi said. “But it brings a lot of challenges to us as vendors because they’re going to use a different EHR and we have to somehow bring the calculation together and try to match it with the right team.”
To alleviate the troubles perpetuated by MIPS flexibilities, providers and vendors alike should get involved to understand MIPS measures and reporting, she advised.
“The whole purpose of the program is to add quality to healthcare and all of us have to have this in mind,” she stated. “What is the purpose behind all these regulation and rules? For us, as a vendor, it’s to deliver the best tool and the best way for the providers to achieve better quality of healthcare. For providers, it’s to find the best way to report and improve the way they work.”
Stakeholders can get involved by submitting comments to CMS on proposed rules and working together to jointly understand the program.
Providers should also particularly benefit by participating in MIPS despite 2017 serving as a transition year.
To ease eligible clinicians into MIPS, CMS created a transition year in which clinicians can opt to just test MIPS and avoid an automatic negative four percent Medicare payment adjustment in 2019. They can also partially or fully participate in the program to earn greater value-based incentive payments.
“I highly recommend that providers get involved, even if it’s only one measure that they want to select and even if it’s a very short duration that they want to report,” she recommended. “It’s a flexible year, and they can submit anything and prevent penalty.”
Clinicians should take advantage of the transition year to receive feedback from CMS on their MIPS performance before that feedback could result in maximum value-based penalties.
“I don’t think this flexible year will ever be repeated, so it’s a great opportunity for a provider to get involved in even though a lot of providers are afraid of participating or even looking into the regulation,” she said. “But it is not that scary for providers to achieve six measures. It’s not really a big deal, and again, it’s just flexible reporting. They have a lot of options. They can do 90 days. They can do the whole calendar year. So, why not take advantage of that by participating?”