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5 ways to create and implement better MIPS quality improvement strategies


MIPS reporting is more complex now, but the more you invest in quality improvement, the stronger your outcomes will be.

MIPS, CMS, Medicare, EHR

The Centers for Medicare & Medicaid Services (CMS) recently announced that 98.4 percent of eligible clinicians participated in the second year (2018) of Merit-based Incentive Payment System (MIPS) reporting - and that 97.6 percent of those earned a positive payment adjustment.

While the initial successes of 2018 and 2017 sound impressive, there’s a hard truth going forward: MIPS reporting just got a lot more difficult for physicians and other providers in 2019 and promises to get even more difficult in 2020.

The agency has increased the performance threshold for “positive financial adjustment” and the threshold for “exceptional” performers has been raised from 70 to 75, meaning physicians will have to do more to earn the designation of top performers. The negative penalty threshold, meanwhile, has doubled from 15 points to 30 points.

On the plus side, CMS is doing more to help small practices through the new bonus programs and resources. But in order to succeed and avoid penalties, physicians will need to do more than just show up. 

Addressing MIPS challenges

One of the biggest challenges we’ve seen so far is that physicians aren’t always sure how to align MIPS with their existing workflows to meet CMS’ Triple Aim Goals of improving health, reducing costs and improving the experience of care. Figuring out how to do this without the proper guidance, tools and insights creates unnecessary redundancies and work.

Also, for many physicians, the mere onset of MIPS has stirred resentment. To some physicians, some of the measures feel unattainable, such as the measure that requires getting patients with high blood pressure to reach a target blood pressure of 140/90 or better. 

But with the right support structures and guidance, physicians can easily avoid the negative 7 percent reduction in Medicare reimbursement and maximize MIPS success.

MIPS tips and tricks

Practices that want to earn positive payment adjustment in the years ahead should adopt the following MIPS reporting strategies used by practices that enjoyed exceptional performer status in 2018:

1. Determine eligibility and target quality measures 

Set your practice up for a win by first checking MIPS-eligibility status through the QPP Participation Status Tool (qpp.cms.gov). Next, target the most appropriate or relevant quality measures. For 2019 reporting, CMS asks practices to report on six measures, or a complete specialty measure set, including one outcome measure. Select at least 10 measures to track throughout the year so your practice has options for choosing the top six quality measures. For now, avoid the quality-based performance metrics, since they could be difficult to perform well enough to quality for incentivized payments. Instead, reduce reporting inefficiencies by aligning with target metrics for other quality improvement initiatives. For example, if your practice has a high population of patients with hypertension or COPD, achieving optimal blood pressure averages for the group is a priority goal.

2. Access consistent data elements to demonstrate achievement 

Too often, physicians improve one performance metric (e.g., blood sugar stabilization) but use multiple workflows to capture this data across a practice or health system. As a result, performance scores do not always reflect the quality of care being provided.

Stop this cycle in 2019. Compare apples to apples and benchmark progress by examining performance through the use of a consistent measuring tool. One way to do this is to leverage data integration technology to aggregate from multiple data sources (e.g., EHRs, practice management systems, chronic disease registries) and pull data into a single repository. A CMS-approved Quality Registry or Qualified Clinical Data Registry (QCDR) can aid with MIPS reporting, facilitate this process and help practices normalize data as well as optimize measures.  

3. Mine data with core competencies in mind 

Practices aren’t suffering from a lack of data - they have droves of it stored in their EHRs. But they only need a small portion of that data to make improvements that align with MIPS goals.

Once a practice has selected its 10 or so measures to focus on for the entire year, improve data extraction efforts by employing three facet data mining by mining quality data codes, other codified data and structured texts to ensure you’re capturing all essential population health information - especially if your EHR can’t trigger quality codes. For example, if three facet data mining for breast cancer screening, you’d first look at mining primary codes (G 9899 and G 9900), then other codified data (e.g., code 24606-0, Breast Mammogram Screening), followed by structured EHR text fields (e.g., mammography, mammogram) to get the complete picture.

4. Develop physician and patient engagement plans 

Engaging both physicians and patients is essential to MIPS success. To engage physicians, assemble a multidisciplinary team comprised of physicians, nursing leaders, administrative staff and IT leaders in order to gain buy-in from clinical and operational staff. Review CMS rules, develop a work plan and ensure that continuing education plans focus on educating physicians in a way that is convenient and accessible.

For patients, focus on tools that engage patients between visits. For example, we know that some practices have employed flu shot campaigns that include timed, targeted email reminders to high-risk patients, and those efforts have led to major improvement in a MIPS performance metric.

5. Assess your data throughout the year

Quality improvement is a year-round activity that requires dedicated staff to monitor data and implement quality improvement programs. Avoid the end-of-year rush by reviewing performance at regular intervals, such as quarterly or monthly. This way, if a problem arises, it can be addressed before it escalates. In addition, continuous improvement positions the organization well for the additional increases in MIPS thresholds and financial impact in 2020 as outlined by CMS in the 2020 Quality Payment Program proposed rule.

While CMS is upping the ante with elevated 2019 MIPS thresholds, practices can see this change as an opportunity to strengthen quality improvement initiatives. A comprehensive, data driven approach to quality improvement ensures practices meet Triple Aim goals and continue to succeed, year after year.

Amy Amick is President and CEO of SPH Analytics, an Alpharetta, Ga.-based healthcare and population health management data analytics firm.

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