In the previous blog we looked at the highlights of the 2019 QPP Proposed Rule for MIPS. In this post we would explore how the 2019 proposed rule will affect the Quality performance category, the category with highest weight. The Meaningful Measures Initiative has initiated the transformation of the Quality performance category. Under this initiative, CMS has been working to identify and define meaningful measures areas that connect CMS’s goals of improving quality, safety, accessibility, and affordability to better patient outcomes. The changes proposed for the Quality category in the 2019 Proposed Rule are definitely a big stride towards making measures more meaningful both for the physicians and the patients. These changes mark the beginning of transition from measuring quality in terms of process to measuring it in terms of outcome.
Now that we have a sense of the bigger picture, let's look at the proposed changes in detail.
Quality Category Weight - 45%
The category weights got redistributed between Quality and Cost as per the provisions of MACRA. But, because of the Bipartisan Budget Act, the Cost category is proposed to account for only 15% of the weight instead of 30% originally finalized. As a result, Quality category still will have the highest weight among the four performance categories of 45% (combined weight of Cost + Quality needs to be 60% for MIPS year 3). Despite the reduction in weight, 6 measures will still be required, out of which one needs to be an Outcome or a High Priority measure.
Quality Reporting Period - 12 Months
Similar to 2018, in 2019 too Quality data will need to be reported for full calendar year - Jan 1, 2019 to Dec 31, 2019.
Quality Submission Methods Restructured for Clarification
In the 2019 proposed rule, Submission Methods and the Reporting Types have been subdivided into 3 sub-parts to match with the submission experience of the clinicians with the 2017 MIPS data. :
Collection Type: a set of quality measures with comparable specifications and data completeness criteria. These are eCQMs, MIPS CQMs, QCDR measures, CAHPS for MIPS survey, and CMS Web Interface measures. Registry measures have been renamed as MIPS CQMs.
Submission Types: the mechanism by which a submitter type submits data to CMS, including, as applicable: direct, log in and upload, log in and attest, Medicare Part B claims and the CMS Web Interface.
Direct: The direct submission type allows users to transmit data through a computer-to-computer interaction (API embedded in the EHR).
Log in and Upload: Enables users to upload and submit data in the form and manner specified by CMS with a set of authenticated credentials (EIDM account).
Log in and Attest: Users manually attest that certain measures and activities were performed in the form and manner specified by CMS with a set of authenticated credentials by logging in to the EIDM account.
3. Submitter Types: MIPS eligible clinician, group (and virtual group), or via a third-party intermediary acting on behalf of clinician or group that submits data on measures and activities under MIPS.
SUMMARY OF SUBMISSION OPTIONS FOR QUALITY CATEGORY
*Medicare Part B Claims measures
*Medicare Part B Claims measures
**CMS Web Interface measures
CMS approved survey vendor measure
|Direct (via API)
Log in and Upload
*Medicare Part B Claims measures
** CMS Web Interface
* Individuals and small practice groups only
** CMS Web Interface available only to groups of 25 or more eligible clinicians
In case you find these terms still confusing CMS is requesting feedback on these terms, which is due by Sep 10, 2018.
Multiple Collection Types Permitted
As promised in the 2018 Final Rule, CMS has proposed that clinicians will be able to submit data for the Quality performance category using multiple collection types. However, because of the way the submission and scoring works, clinicians submitting data as individuals might have a little more flexibility than clinicians submitting MIPS data as a group.
In 2019, individual eligible clinicians will be able to submit a single measure via multiple collection types (eCQMs, MIPS CQMs, QCDR measures, Medicare Part B Claims measures). They would be scored only on the data collection type with the greatest number of measure achievement points.
Clinicians submitting data as a group can also submit data for Quality category via multiple applicable collection types (except groups using CMS Web Interface). However, we would need to wait for the 2019 Final Rule to find out if Groups can do so for each measure like the individual clinicians can. All the group options will also applicable to the Virtual Groups.
Medicare Part B Claims available to Small Practice Groups
Another major change is that Medicare Part B Claims, which was only available to individual clinicians in previous performance years (2017 and 2018), will be available to Small Practice Groups (1-15 eligible clinicians) in 2019 performance year.
There are some significant changes proposed for the Quality category scoring, facility-based scoring and change in small practice bonus being the most important ones. However, some aspects of scoring remain the same as MIPS year 2.
1. Facility Based Scoring: Facility-Based scoring will be available in 2019 to the facility-based MIPS eligible clinicians and groups for both Quality and Cost performance categories. The 2019 measure set for Hospital Value-Based Purchasing (VBP) program will be used.
Individuals – Furnish ≥75% of the covered professional services in inpatient hospital, on-campus outpatient hospital, as identified by POS code 22, or an emergency room based on claims for a period prior to the performance period. Clinician must have at least one service billed with the POS code used for the inpatient hospital or emergency room.
Groups – 75% or more of the eligible clinicians in the group TIN qualify for Facility-Based measurement as individuals
2. Small Practice Bonus: This bonus has now been moved to the Quality Performance Category instead of adding 5 points to the MIPS score (in 2018). For 2019, 3 points will be added to the numerator while calculating the Quality performance category score. A small practice that is required to report 6 measures will get about 5% boost to the Quality Category Score. [(3/60)*100 = 5% ] Based on the reporting statistics of MIPS Year 1, CMS estimates that the impact would be much bigger than 5% when both the PI and the Cost category are reweighted to Quality category and it accounts for 85% of the MIPS score.
3. Sample Requirement Not Met for CAHPS for MIPS Measure: CAHPS for MIPS survey measure will not be scored if the survey results don’t meet the specified sample size. So, to eliminate the negative impact on the MIPS score, CMS is proposing to reduce the denominator (that is, the total available measure achievement points) for the quality performance category by 10 points for groups that register for the CAHPS for MIPS survey but do not meet the minimum beneficiary sampling requirements. That means that the measure requirement will be reduced by one measure for those groups (5 measures instead of 6 required measures).
4. Measures Impacted by Clinical Guideline Changes: In case the clinical guidelines change in the middle of the performance year and the change impacts the definition and data reporting for the measures, those measures will not be scored. If a clinician reported one such measure, the measure would be allocated a score of 0 and the Quality performance category denominator reduced by 10. Thus, the clinician would be scored on 5 instead of 6 measures.
5. Quality Performance Improvement Scoring: Stays the same as that of MIPS 2018 performance year.
6. 60% Data Completeness Required: Less than 60% data completeness will earn just 1 point for all practices except small practices. Small practices (1 to 15 eligible clinicians) will still be able to earn 3 points for a measure even if they fall short on the data completeness requirement.
Other Significant Changes in the Quality Performance Category
1. Medicare Claims for Small Practices: Another big change proposed for the Small Practices (1-15 eligible clinicians) is that the Medicare Claims is now being opened up to small practices reporting as a group. In contrast, Medicare Claims was/is available to those submitting MIPS data as Individuals only in 2017 and 2018 performance years.
2. CMS Web Interface for Groups of 16 or More: It is proposed to make CMS Web Interface collection type available for groups of 16 or more eligible clinicians (currently available only to groups of 25 or more). Also, the high-priority measure bonus points for CMS Web Interface are proposed to be removed.
3. Quality Measures Updates Under the Meaningful Measures Initiative: This initiative is a subset of Patients Over Paperwork Initiative and embodies a new approach to quality measures. It focuses on creating measures that are conducive to creating operational efficiencies, reducing costs, and reducing reporting burden by providing clinicians the flexibility to select and report the measures that matter most to their practice and patients. CMS aims to make significant strides in this area in 2019 performance year by:
Adding 10 new MIPS Quality Measures
- 4 patient reported outcome measures
- 7 high priority measures (including one related to Opioid use disorder)
- 1 measure that replaces an existing measure
- 2 other measures on important clinical topics in the Meaningful Measures framework
Removing 34 Quality Measures
As you can gather , Quality measures are undergoing a major overhaul. If you want your voice to be heard, chime in, and submit your comment to CMS by Sep 10, 2018. CMS has also been doing a lot of testing with the Cost measures as it is important to strike the perfect balance between Cost and Quality to move towards a more efficient healthcare system. So, in the next blog (Part-III), we would talk about changes proposed under Cost performance category.