Stephen Besch

The Transition to MACRA: Six Best Practices for Inpatient Quality Reporting

By Stephen Besch
Senior Systems Analyst, Director of Clinical Quality Reporting
Ingenious Med

The Quality Reporting Program under the new MACRA legislation is slated to replace the Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM), and the EHR Meaningful Use programs beginning January 1, 2017. Under MACRA’s Quality Payment Program, penalties and reimbursements will quickly rise to levels never before associated with CMS evaluations.
One track to successfully navigating the Quality Payment Program is known as the Merit-Based Incentive Payment System (MIPS). There are four elements that contribute to an overall “composite” score under MIPS: Quality, Cost, Improvement Activities, and Advancing Care Information. During the first year of MIPS, the Quality component was originally projected to comprise 50 percent of the weighted MIPS score. However, CMS has chosen to reduce the Cost component of the MIPS score from 10 percent to 0 percent for the first year, which increases the relative weight of the Quality category for all participants. Additionally, any clinician with 90 percent or more of his or her Medicare charges associated with Place of Service Codes 21 (inpatient hospital) or 23 (emergency department) will be classified as hospital-based clinicians and, as such, will have the 25 percent weighting of the Advancing Care Information component of MIPS reduced to 0 percent as well. With only the Improvement Activities (originally weighted at only 15 percent) and Quality categories remaining, the net effect of these adjustments means the weight of the Quality score will become the most critical factor, by far, in determining success or failure within the program.

Since the quality reporting process under the new MIPS Program will remain virtually identical to the existing PQRS reporting process, groups who have successfully reported PQRS data in the past will likely continue to be successful under the new system. However, nearly 10 years after implementation of the PQRS program, many inpatient physician groups still struggle to successfully meet their quality reporting requirements. In this article, we will review six key elements that can contribute significantly to successful quality reporting under MIPS.

1 – Capture your performance data electronically

I’m still amazed at the number of practices attempting to capture their quality-performance data using paper tools. Capturing data in this way relies heavily on the physician to determine when a quality measure applies to her or his patient and to remember to document it properly in each of those cases. This places additional burdens on physicians while they are attempting to focus on the patient’s needs, and it increases the likelihood of failing to capture their performance data.
An electronic system that monitors the patients’ demographic information, their diagnoses, and the services the physician provides for them, then prompts the physician to document quality measures applicable to that encounter is invaluable in consistently recording quality measure performance. Not only does it remove the burden of applying quality-measure definitions for the clinician, but it can also serve as a reminder to them of the ever-changing gold standards in patient care for specific conditions.
An electronically prompted system is a quick, easy, and reliable way for clinicians to record their performance on quality measures. Capturing measure performance electronically can also enable real-time report generation to track the progress of each team member, while there is still time to make improvements for clinicians with deficiencies.

2 – Don’t rely on claims-based reporting

Claims-based reporting, while free, has historically resulted in success rates hovering around the 50-percent mark. With multiple handoffs of quality reporting data between the practice and CMS (with this non-billable data flowing through a system that was largely designed to prevent the passage of non-billable data), much of the performance data transmitted by the clinicians simply evaporates before reaching CMS.
There are multiple alternative submission methods that, though they may require a small financial investment to complete, will dramatically improve the likelihood that your quality reporting data will actually reach CMS. Qualified Registries, Qualified Clinical Data Registries, and EHR reporting are alternative submission methods that greatly improve data transmission reliability (with success rates approaching 100 percent).

If your physicians have done the work of capturing their measure performance throughout the year, and if their answers reflect good performance on their quality measures, it’s worth the extra effort of completing an alternative submission method to make sure they get credit for the work they have done. The small amount of money spent in completing that submission will pay off handsomely in penalty avoidance and potential incentives awarded.

3 – Get your physicians involved

The best data-capturing systems and the most reliable data-submission methods are of little use if your physicians are not on board with your quality-reporting efforts. Despite having the best available infrastructure, lack of physician support is frequently the cause of failed quality reporting.
Attempting to report quality measures that don’t apply to your clinicians’ scope of practice (e.g., requesting that surgeons report a quality measure related to flu vaccinations) is a common issue that drives physician participation levels down.

Some practices have found success in making physician bonuses dependent upon their reaching a minimum performance level within their individual quality reporting. Reminding the team that individual quality-measure performance will eventually be posted to the CMS Physician Compare website can also be a strong motivator for improved cooperation.

4 – Choose your quality measures wisely

Selecting which quality measures to report can be confusing. Measure titles can be misleading, making a measure seem applicable to your physicians even though they never bill the CPTs that actually put patients into the reporting denominator for the measure. A statistical analysis of your billing patterns is the first step in determining what your reporting options are. A measure with low denominator counts (sample size) for your physicians can be a risky choice. With very few reportable instances available during the course of the year, a single negative event can inordinately skew their performance ratings and offer them little or no opportunity to improve their scores.
Once you know which measures are reportable by your clinicians, in the statistical sense, you should further evaluate those measures for clinical applicability. Aligning your quality-reporting measures with services your physicians actually provide to patients is another key to selecting the best quality measures for your team. Our example from the previous section, requiring surgeons to report a measure related to flu vaccinations, is a poor fit for their scope of practice. If they do report the measure consistently, they’re still likely to report low performance due to the clinical disconnect.
Selecting quality measures that align with the clinical scope of practice and the workflow of your physicians is an important step in setting the stage for successful participation, from the perspective of maintaining high reporting rates as well as high performance rates.

5 – Manage your MAV exposure

Measure Applicability Validation (MAV) is a powerful, yet little-known, aspect of clinical quality reporting. CMS recognizes that specialty physicians who bill in a regimented pattern may have limited quality measures available to report. This is particularly true of inpatient physicians, whose billing is primarily limited to only Admissions, Follow-Ups, and Discharges. There may simply not be enough measures available (with consistent denominator populations) to reach the program minimums for many of these physicians. That is where a keen understanding of MAV can serve you well.
CMS gathers clinically related measures into MAV “clusters” (e.g., Diabetes, Stroke, General Surgery, etc.). CMS surmises that, if clinicians can report one measure from a cluster, they are usually capable of reporting the other measures within that same cluster. In that way, reporting a measure from a given cluster can obligate the clinician to report all of the other measures within that cluster. There are, however, some quality measures that do not belong to MAV clusters. Reporting these measures would not obligate the physician to report additional measures.

When a clinician reports fewer than the required number of quality measures (six quality measures are required for maximum Quality scores under MIPS), CMS will review the measures they did report, then assess whether or not there were additional measures clustered with those measures the clinician could have reported. If they find measures cluster with a reported measure that could have been reported, but weren’t, the clinician would fail their MAV evaluation and their quality score would be lowered.
If, however, the MAV search does not find any clustered measures that were reportable but omitted (i.e., the clinician either reported all of the measures in the cluster and/or measures that were not in clusters), the physician is held harmless for falling short of the minimum measure count and can still earn a maximum score for Quality reporting.

If the physician is not guaranteed to reach the minimum of six quality measures to satisfy the MIPS reporting requirement, MAV clusters must be taken into careful consideration when selecting the quality measures they will report. When selecting a measure belonging to a MAV cluster, any additional measures (applicable to your billing) within that cluster should be reported as well. Measures that do not belong to MAV clusters are generally a safe option to report as well.

6 – Don’t forget your cross-cutting and outcome/high-priority measures

Regardless of the total number of quality measures reported, two additional MIPS requirements stipulate specific measure types that must be included. Each participating clinician must report at least one outcome measure. If there is no outcome measure available to them, they must, instead, report at least one measure from a list of measures classified by CMS as “high priority” to satisfy this requirement. In addition, any clinician who has at least one face-to-face encounter with a patient during the participation period must also include at least one quality measure from a list of measures classified by CMS as “cross-cutting.” No matter how many measures a participant successfully reports (and no matter how stellar their performance ratings may be on those measures), their MIPS Quality score will be lowered if they do not meet these cross-cutting and outcome/high-priority measure requirements within their reporting.