Strategies to Measure Performance and Enhance Quality Under MIPS

January 23, 2018 3:39 pm

Access to flexible, robust tracking tools that produce a range of actionable data are proving crucial for physicians participating in the primary track of MACRA.

When considering technology for gathering the information needed to succeed in the Merit-based Incentive Payment System (MIPS), provider organizations should think holistically.

“You have to have a system that pulls clinical data from all sources and compiles it around the patient, not just the hospital record,” says Jeffery Gubbels, MD (pictured at right), chief medical officer and vice president of medical operations for Memorial Hermann Medical Group in Houston.

For 2018, the Medicare Access and CHIP Reauthorization Act (MACRA) calls for eligible individuals and groups to participate in MIPS unless they qualify for an exemption or are participating in an advanced alternative payment model. Compensation will be determined by performance of physicians and other types of clinicians in four categories: advancing care information (ACI), at least six quality measures selected from more than 200 options, clinical practice improvement activities, and cost measures.

The performance period for the quality- and cost-performance categories takes place Jan. 1 through Dec. 31, with a minimum of a 90-day period to measure improvement activities and ACI performance. The first payment adjustments go into effect on Jan. 1, 2019, based on 2017 performance, while this year’s performance affects payment in 2020. For the 2018 performance year, the maximum payment bonus or penalty is 5 percent.

Tracking Tools and Learning Opportunities

To successfully report on ACI, healthcare organizations must have access to certified electronic health record (EHR) technology, using the most appropriate tools to track required information and identify growth opportunities. 

Quality-related tools and strategies for implementation. An EHR offers a detailed view of patient care information across an organization but may not provide a comprehensive view of a patient or allow organizations to compile information that is needed to examine quality of care. Provider organizations thus have invested in multiple tools, pooling information from a range of sources to achieve a complete picture of individual patients and populations. 

Comprising approximately 335 providers, Memorial Hermann Medical Group uses an EHR, quality-reporting system, and a data warehouse to track MIPS measurements. “By compiling claims data and all known clinical information from every available source, you can get a more global picture of your patients’ health care and things that need to be addressed by primary care physicians,” Gubbels says. The organization’s data warehouse currently looks at dozens of sources of patient information, including individual patient records, healthcare cost data, and population health analytics.

St. Joseph Heritage Healthcare gathers data from sources including the Centers for Medicare & Medicaid Services (CMS), claims, and lab results to understand where physicians stand in terms of quality. A physician practice management organization that is part of Providence St. Joseph Health and includes eight medical groups and six affiliated physician networks throughout California, Anaheim-based St. Joseph Heritage Healthcare utilizes an EHR, quality-reporting system and a data warehouse to track MIPS measurements.

“We want as much relevant data as we can get because when we have accurate, complete, and current data, we know what care gaps need to be filled instead of what data gaps exist,” says Christy Mokrohisky (pictured at right), vice president of population health for St. Joseph Heritage Healthcare. 

When investing in tracking tools, organizations must also consider methods of staff support during implementation. “You can’t just buy a machine; you have to actually have a whole human resource around people that can analyze, utilize, and report the information back to you,” says Grace Terrell, MD, CEO of Envision Genomics. Data analysts who have an understanding of clinical data will be crucial for organizations, she says.

Tools to identify areas of improvement. To better understand opportunities for improvement, health systems can rely on certified technology that may be customized to track specific quality measures. 

“Unless the tool enables a sufficient drill-down of the information to a truly actionable level for the physician, you may well have a situation where you’ve spent a lot of money on the tool, but the tool doesn’t actually deliver information that a physician needs to be able to change,” says Harold Miller, president and CEO, Center for Healthcare Quality and Payment Reform.

Using quality results from its participation in the Medicare Shared Savings Program as a guide, Memorial Hermann Medical Group has focused on helping physicians improve in the areas of diabetes eye exams, mammogram screening reminders, and colonoscopy screenings. The organization has customized its tracking tools to reflect MIPS measurements, tying physician quality compensation and individual bonuses to the results, with up to 10 percent of total income at risk under targeted measures.

“Knowing that’s where the puck’s going to be in five, six, seven years from now, our team built that [quality measurement] into the product [the quality-reporting system] from the beginning, and the team that did all the data programming incorporated those ideas,” Gubbels says. 

Data warehouses enable provider organizations to house data ranging from EHR to CMS to claims and lab. “You can build your own reports to help close gaps in care,” says Kevin Manemann (pictured at right), president and CEO, St. Joseph Heritage Healthcare. “When you identify a specific population that you want to measure, you write an actionable report ad hoc.” St. Joseph Heritage Healthcare utilized information garnered from such tools to identify an opportunity to improve its MIPS measurements in depression screening.

Decisions to Make and Resources to Consider

MIPS calls for eligible providers to explore how to optimize their performance in the designated categories. Mokrohisky points out some of the considerations: “You can invest in an EHR and train staff on how to build quality reports. You can align your data with a larger provider organization that can support you in the reporting. Or you can decline to participate fully in MIPS and take a potential penalty.”

CMS has created hardship exceptions for some MIPS-eligible participants, allowing them to bypass the ACI category and reallocate that portion of their score to the Quality category. Such exceptions are available for organizations that lack sufficient Internet services, are facing unmanageable circumstances, or have no control over obtaining needed tracking technology. 

CMS has also allocated $20 million a year over five years to select organizations that will support MIPS-participating practices with 15 or fewer eligible clinicians and those operating in underserved areas. These organizations will provide education, training, and technical assistance in choosing and reporting on quality measures. 

When looking at ways to establish a range of information to better understand performance, organizations may build on data already in place by repurposing tools. “For example, with billing technology, you can pull up, depending on the instrument you’re using, every patient you’ve had that you’ve sent a claim out for with a particular diagnosis over a period of time,” Terrell (pictured at right) says, noting that claims data can provide details on individual patients, services provided, and demographic data. Organizations would be able to address any quality issues based on what the claims data indicate and examine the capabilities of current practice management system technology to ensure it is being used to its maximum benefit.

Solo practitioners and group practices can also reference CMS’s Quality and Resource Use Reports (QRURs), which include data on performance in quality and cost measures. These reports help clinicians and practices understand how their measures compare to national benchmarks, and any resulting payment adjustment.

Another resource is CMS’s Qualified Entity (QE) Program, which allows providers in some parts of the country to receive analyses of claims data from designated QEs for use in evaluating performance. “QEs have access to both CMS data and to commercial data and are able to provide analytic information to physicians and provider organizations about how they’re doing and how they compare to others,” Miller says.

Employing Data to Implement Change

Provider organizations can use the information they gather as part of MIPS tracking to improve quality and reduce unnecessary utilization by employing multiple levels of expertise, ranging from clinical to analytics.

“When you share information with doctors, you very quickly identify errors and defects in your system,” Gubbels says. “We have a system-level quality committee tasked with doing the PDCA [plan-do-check-act] on the individual quality measure.” 

This process has helped Memorial Hermann Medical Group deliver diabetes eye exams more efficiently by improving communication between primary care physicians and specialists through tele-ophthalmology.

With handheld retinal cameras in their offices, primary care physicians use the group’s quality-measure reporting tool to identify diabetics who have not recently had a screening for retinopathy and to capture images along with vital signs during intake. An ophthalmologist receives this information and evaluates it electronically, and results flow back to the EHR. Such efforts have helped the medical group improve in this quality category by 25 percent in six months.

To address areas that need improvement, St. Joseph Heritage Healthcare employs a team approach to communicate measure requirements and each measure’s purpose. “You get physician champions together with the people who interpret the reports to understand exactly where the opportunities are and what action to take. Then you disseminate the individual provider reports with support of your physician champions,” Manemann says. “The quality specialists and data analytics experts support the process.” 

When identifying depression screenings as a growth opportunity, St. Joseph Heritage Healthcare built an alert for providers while also training them on the new process. The organization’s information systems now alert physicians to patients who should be screened. While improving the screening process, the organization also ensures that needed resources are available for patients who screen positively for depression. 

Mokrohisky notes the importance of communicating with physicians to emphasize the difference being made: “Once you’ve had an intervention such as a point-of-care alert and develop a new workflow to support it, you can run a report to show a change in outcomes. When you share information back with the provider office, they see the care gaps that they closed and how their work made a difference.”

Elizabeth Barker is a digital communications professional and freelance writer in Chicago.

Interviewed for this article: Jeffery Gubbels, MD, chief medical officer and vice president of medical operations, Memorial Hermann Medical Group, Houston; Kevin Manemann, president and CEO, St. Joseph Heritage Healthcare, Anaheim, Calif.; Harold Miller, president and CEO, Center for Healthcare Quality and Payment Reform, Pittsburgh; Christy Mokrohisky, vice president, population health, St. Joseph Heritage Healthcare, Anaheim, Calif.; Grace Terrell, MD, CEO, Envision Genomics, Huntsville, Ala.


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