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1 2018 Quality Performance Category Scoring for Alternative Payment Models
2 CONTENTS 2018 Quality Performance Category Scoring for Alternative Payment Models ___ 1
TABLES ___ 2
Section 1: Introduction ___ 4
1.2 Purpose of this Document ___ 6
1.3 Organization of this Document ___ 6
Section 2: Overall APM Scoring Standard ___ 7
2.1 Performance Period for APM Scoring ___ 7
2.2 APM Participant Identifier and APM Entity Group Determination ___ 7
2.3 APM Performance Categories and Weights ___ 8
2.4 Total APM Entity Score ___ 8
Section 3: MIPS APMs in 2018 ___ 10
3.1 Medicare Shared Savings Program ___ 10
3.2 Next Generation ACO ___ 16
3.3 Comprehensive Primary Care Plus Model ___ 16
3.4 Oncology Care Model ___ 21
3.5 Comprehensive End-Stage Renal Disease Care Model ___ 23
Section 4: APM Scoring Standard for the Quality Performance Category ___ 28
4.1 Quality Measures Achievement Points ___ 28
4.2 Bonus Points in the Quality Performance Category ___ 31
4.3 Quality Improvement Score ___ 32
4.4 Total Quality Performance Category Score ___ 32
4.5 2018 APM Scoring Standard for CMS Web Interface Reporters ___ 33
4.6 2018 APM Scoring Methodology for Other MIPS APM ___ 41
TABLES 1.1 MIPS APMs ___ 5
Table 3.1 Description of each track of the Shared Savings Program and the Track 1+ Model ___ 11
Table 3.2 Shared Savings Program and Next Generation ACO Model 2018 MIPS APM Measure List ___ 11
Table 3.3 Comprehensive Primary Care Plus Model 2018 MIPS APM Measure List .
3 Table 3.4 Oncology Care Model 2018 MIPS APM Measure List ___ 22
Table 3.5 Comprehensive ESRD Care Model 2018 MIPS APM measure list ___ 24
Table 4.2 Comprehensive ESRD Care Quality Performance Category Percentage Score Calculation ___ 42
Table 4.3 Comprehensive Primary Care Plus Quality Performance Category Percentage Score Calculation ___ 46
(continued ___ 47
Table 4.4 Oncology Care Model Quality Performance Category Percentage Score Calculation . . 50
4 Section 1: Introduction The Quality Payment Program (QPP), established by the Centers for Medicare & Medicare Services (CMS) in accordance with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), is a quality payment incentive program for physicians and other eligible clinicians, which rewards value and outcomes in one of two ways: through the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).1 Advanced APMs are a subset of APMs that provide added incentives for high-quality and costefficient care and require participants to use certified EHR technology and hold a financial stake in quality and cost outcomes of their beneficiaries.
APMs may attempt to improve the quality or cost of a specific clinical condition, care episode, or population.2 As prescribed by MACRA, MIPS has four performance categories: (1) Quality—including a set of evidence-based, specialty-specific standards; (2) Cost; (3) practice-based Improvement Activities; and (4) Promoting Interoperability (formerly Advancing Care Information) —use of certified electronic health record (EHR) technology (CEHRT) to support interoperability and advanced quality objectives in a single, cohesive program that avoids redundancies.3 Performance in these categories is scored and weighted, and a MIPS final score is calculated for determining payment adjustments 2 years later.4 Eligible clinicians can be assessed and scored for MIPS as individuals, part of a MIPS group, part of a MIPS virtual group, or as part of an APM Entity group.
The scoring procedures for MIPS individuals, groups, and virtual groups are described elsewhere.5 This document describes how eligible clinicians who are part of an APM Entity group will be assessed under the quality performance category in MIPS. Certain APMs include MIPS eligible clinicians as participants and reward their participants for improving the cost and quality of care provided to Medicare beneficiaries. This type of APM is called a “MIPS APM,” and participants in MIPS APMs have MIPS-specific reporting requirements and receive special MIPS scoring under the “APM scoring standard.” MIPS APMs are those in which: 1.
APM Entities participate in the APM under an agreement with CMS or through a law or regulation; 2. The APM is designed such that APM Entities participating in the APM include at least one MIPS eligible clinician on a Participation List; 3. The APM bases payment on quality measures and cost/utilization; and 4. The APM is not either of the following: a. New APM: An APM for which the first performance year begins after the first day of the MIPS performance period for the year.
1 https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/QPP-Y ear-2-Final-Rule-Fact-Sheet.pdf 2 https://qpp.cms.gov/apms/overview 3 https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/QPP-Y ear-2-Executive-Summary.pdf 4 https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2017- MIPS-101-Guide.pdf 5 https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/MIPSScoring-101-Guide.pdf
5 b. APM in final year of operation for which the APM scoring standard is impracticable: An APM in the final year of operation for which CMS determines, within 60 days after the beginning of the MIPS performance period for the year, that it is impracticable for APM Entity groups to report to MIPS using the APM scoring standard.6 Most Advanced APMs are also MIPS APMs; if an eligible clinician participating in the Advanced APM that is also a MIPS APM does not meet the threshold level of payments or patients through an Advanced APM to become a Qualifying APM Participant (QP), the eligible clinician will be scored under MIPS according to the APM scoring standard.7 However, these participants will not be burdened with double-reporting quality to both the APM and MIPS.
If they already report quality data for payment purposes within their respective model, they will not have to separately report quality data under MIPS.
The APM scoring standard does not apply to an APM that includes only facilities as participants. The standard also does not apply to a QP in an Advanced APM for the year, because that eligible clinician is excluded from the MIPS reporting requirements and payment adjustment for the year. Eligible clinicians that are Partial QPs for the year can choose as an APM Entity whether to participate in MIPS.8 1.1 MIPS APMs There are six MIPS APMs in 2018: (1) Comprehensive End-Stage Renal Disease (ESRD) Care (CEC) Model, (2) Comprehensive Primary Care Plus (CPC+) Model, (3) Medicare Shared Savings Program, (4) Next Generation ACO Model, and (5) Oncology Care Model (OCM), (6) Medicare ACOs Track 1+ Model Table 1.1 shows the list of MIPS APMs in 2018, categorized by their track or arrangement, along with their Advanced APM status and whether they are a medical home model.9 Table 1.1 MIPS APM in 2018 APM MIPS APM Under the APM Scoring Standard Medical Home Model Advanced APM Comprehensive ESRD Care (CEC) Model (Large Dialysis Organization [LDO] arrangement) Yes No Yes Comprehensive ESRD Care (CEC) Model (non-LDO two-sided risk arrangement) Yes No Yes 6 42 C.F.R.
414.1370(b) 2017. 7 https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Compr ehensive-List-of-APMs.pdf 8 https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/MIPSAPMs-in-the-Quality-Payment-Program.pdf 9 https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Compr ehensive-List-of-APMs.pdf
6 APM MIPS APM Under the APM Scoring Standard Medical Home Model Advanced APM Comprehensive ESRD Care (CEC) Model (non-LDO one-sided risk arrangement) Yes No No Comprehensive Primary Care Plus (CPC+) Model Yes Yes Yes Medicare Accountable Care Organization (ACO) Track 1+ Model10 Yes No Yes Medicare Shared Savings Program — Track 1 Yes No No Medicare Shared Savings Program — Track 2 Yes No Yes Medicare Shared Savings Program— Track 3 Yes No Yes Next Generation ACO Model Yes No Yes Oncology Care Model (OCM) (one-sided Risk Arrangement) Yes No No Oncology Care Model (OCM) (two-sided Risk Arrangement) Yes No Yes 1.2 Purpose of this Document The purpose of this document is to describe the APM scoring standard for the quality category for MIPS APMs.
The quality performance category is one of four categories used for the MIPS performance assessment. Here, we aim to (1) summarize the regulatory requirements for 2018 APM scoring; (2) describe the quality measures from APMs that are MIPS APMs in the 2018 performance period; and (3) describe the standardized APM scoring methodology for these MIPS APMs that accommodates differences in their quality reporting requirements. The scoring standards for the other APM categories can be found in the 2018 Quality Payment Program Final Rule.11 1.3 Organization of this Document Section 2 describes the overall APM scoring standard under regulations.
Section 3 describes the 2018 Advanced APMs in terms of their data sources and availability of their quality results and benchmarks. Section 4 describes the 2018 scoring methodology for the quality category specifically for MIPS APM “Web Interface” submitters, as well as the participants in “Other MIPS APMs.” 10 ACOs participating in the ACO Track 1+ Model must maintain participation in Track 1 of the Shared Savings Program and remain subject to the Shared Savings Program quality performance standards and reporting requirements at 42 CFR Part 425 Subpart F which are relevant to the APM scoring standard under MIPS.
As such, for purposes of the APM scoring standard, MIPS eligible clinicians in the ACO Track 1+ Model are considered to be participating in Track 1 of the Shared Savings Program. 11 https://www.gpo.gov/fdsys/pkg/FR-2017-11-16/pdf/2017-24067.pdf
7 Section 2: Overall APM Scoring Standard The 2017 Quality Payment Program Final Rule,12 together with the updates specified in the 2018 Quality Payment Program Final Rule,13 established the regulations for MIPS scoring. The APM scoring standard is the MIPS scoring methodology applicable to MIPS eligible clinicians identified on the Participation List for the performance period of an APM entity participating in a MIPS APM.14 2.1 Performance Period for APM Scoring The MIPS performance period applies for the APM scoring standard. For the 2018 performance year, which corresponds to the 2020 payment year, the APM scoring standard performance period for the quality performance category is calendar year (CY) 2018 (January 1, 2018, through December 31, 2018).
For the PI and improvement activities performance categories, the 2018 performance period is a minimum of a continuous 90-day period within CY 2018, up to and including the full CY 2018.15 2.2 APM Participant Identifier and APM Entity Group Determination The APM participant identifier for an eligible clinician is the combination of four identifiers: (1) APM identifier (established for the APM by CMS); (2) APM Entity identifier (established for the APM Entity by CMS); (3) Medicare-enrolled billing tax identification number (TIN); and (4) eligible clinician national provider identifier (NPI).
For the APM scoring standard, eligible clinicians are grouped and assessed through their collective participation in an APM Entity that is in a MIPS APM. To be included in the APM Entity group for purposes of the APM scoring standard, an eligible clinician’s APM participant identifier must be present on a Participation List of a MIPS APM on one of the following dates: March 31, June 30, or August 31 of the Performance Period. An eligible clinician included on a Participation List on any one of these dates is included in the APM Entity group even if that eligible clinician is not included on that Participation List at one of the prior or later listed dates.16 In addition to the dates set forth above, in 2018, an eligible clinician who is on a Participation List in a Full TIN APM on December 31 of the MIPS performance period will be included in the APM Entity group.17 The MIPS final score calculated for the APM Entity group is applied to each MIPS eligible clinician in the APM Entity group.
The MIPS payment adjustment is applied at the TIN/NPI level for each of the MIPS eligible clinicians in the APM Entity group. For a Shared Savings Program ACO that does not report data on quality measures as required by the Shared Savings Program, each ACO participant TIN will be treated as a unique APM Entity for purposes of the 12 https://www.gpo.gov/fdsys/pkg/FR-2016-11-04/pdf/2016-25240.pdf 13 https://www.gpo.gov/fdsys/pkg/FR-2017-11-16/pdf/2017-24067.pdf 14 42 C.F.R. § 414.1370(a) 2017 15 42 C.F.R. § 414.1370(c); see id. § 414.1320(b) 2017 16 42 C.F.R. § 414.1425(b)(1) 2017 17 42 C.F.R.
414.1370(e)(1) 2017
8 APM scoring standard, and the ACO participant TINs may report data for the MIPS quality performance category according to the MIPS group submission and reporting requirements. MIPS eligible clinicians who have elected to participate in a virtual group and who are also on a MIPS APM Participation List will be included in the assessment under MIPS for purposes of producing a virtual group score and under the APM scoring standard for purposes of producing an APM Entity score. The MIPS payment adjustment for these MIPS eligible clinicians is based solely on their APM Entity score.
2.3 APM Performance Categories and Weights The performance category weights used to calculate the MIPS final score under the APM scoring standard for an APM Entity group for the 2018 performance period are as follows: 1.
Quality: 50 percent; 2. Cost: 0 percent; 3. Improvement Activities: 20 percent; and 4. Promoting interoperability: 30 percent. However, if CMS determines there are not sufficient measures applicable and available to MIPS eligible clinicians in the quality performance category, the performance categories will be weighted as follows: 1. Quality performance category is reweighted to 0 percent; 2. Improvement Activities performance category is reweighted to 25 percent; and 3. Promoting interoperability performance category is reweighted to 75 percent. On the other hand, if the MIPS eligible clinicians in an APM Entity group qualify for a zero percent weighting for the promoting interoperability performance category, then the performance categories will be weighted as follows: 1.
Quality performance category is reweighted to 80 percent; and 2. Improvement Activities performance category will remain at 20 percent. 2.4 Total APM Entity Score CMS scores each performance category and then multiplies each performance category score by the applicable performance category weight. CMS then calculates the sum of each weighted performance category score and then adds all applicable bonuses. Each MIPS eligible clinician receives a final score of zero to 100 points for a performance period for a MIPS payment year. If an APM Entity group is scored on fewer than two performance categories, they receive a final score equal to the performance threshold.
9 APM Entity groups will receive MIPS bonuses applied to the final score, just as eligible clinicians who are scored as individuals or as part of a MIPS group or virtual group. There are two bonuses available for the 2018 performance period18 : (1) Complex patient bonus. If the APM Entity submits data for at least one MIPS performance category during the 2018 MIPS performance period, a complex patient bonus will be added to APM Entity’s final score for the 2020 MIPS payment year based on the beneficiary weighted average Hierarchical Condition Category (HCC) risk score for all MIPS eligible clinicians, and the average dual-eligible ratio for all MIPS eligible clinicians, not to exceed 5.0; and (2) Small practice bonus.
A small practice bonus of 5 points will be added to the final score for the 2020 MIPS payment year for APM Entities that meet the definition of a small practice19 and participate in MIPS by submitting data on at least one performance category in the 2018 MIPS performance period. Thus, the MIPS final score is calculated as the sum of each performance category percent score multiplied by its weight, multiplied by 100, and including the two bonuses if applicable, all not to exceed 100 points: Final Score [ ( quality performance category percent score x its weight) + (cost performance category percent score x its weight) + (improvement activities performance category score x its weight) + (PI performance category score x its weight)] x 100} + [the complex patient bonus + the small practice bonus] 2.5 Flow of Data The APM Program Analysis Contractor will calculate the quality performance category percent score, using the quality measure information submitted by each APM Entity as required for participation in their respective APM.
This quality performance category percent score, calculated from the performance results across the measures and including bonus points, will be sent to the MIPS system. Note that submissions for MIPS APMs that are Web Interface Reporters will be automatically calculated and scored for achievement points and bonus points for MIPS with other MIPS eligible clinicians reporting through the Web Interface, and according to Web Interface quality measure scoring procedures.
The MIPS team, rather than the APM Program Analysis Contractor, will then be responsible to aggregate the results from the quality performance category, as well as the improvement activities performance category and the PI performance category, apply appropriate category weights for each performance category, and generate a weighted MIPS final score with any applicable bonus points as specified above for each MIPS eligible clinician in a MIPS APM Entity. 18 42 C.F.R. §414.1380 (b) 2017 19 42 C.F.R.§ 414.1305 2017
10 Section 3: MIPS APMs in 2018 In 2017, MIPS eligible clinicians participating in Shared Savings Program ACOs and Next Generation ACOs were the only APM participants under the APM scoring standard whose MIPS final score was calculated based on quality measures submitted via the CMS Web Interface and included the quality performance category under MIPS.
The quality performance category had a weight of 50 percent on the MIPS final score for these ACOs. APM Entity groups in all other MIPS APMs had a weight of zero for the quality performance category for the 2017 performance period.
Beginning in 2018, MIPS eligible clinicians participating in other MIPS APMs will be scored for the quality performance category under the APM scoring methodology. Unlike APMs that require reporting via the CMS Web Interface (Web Interface Reporters), these MIPS APMs, referred to as “Other MIPS APMs,” do not require reporting through the CMS Web Interface and include participants in OCM, CPC+, and CEC Model. The following sections describe each 2018 MIPS APM and the expected quality measures that will be used for APM scoring standard purposes.
3.1 Medicare Shared Savings Program The Shared Savings Program is a voluntary program that encourages groups of doctors, hospitals, and other health care providers to come together as an APM Entity, known as the Accountable Care Organization (ACO) to provide coordinated, high-quality care to their Medicare patients.
An ACO agrees to be held accountable for the quality, cost, and experience of care of an assigned Medicare fee-for-service (FFS) beneficiary population. The Shared Savings Program offers different participation options (tracks) that allow ACOs to assume various levels of risk. The Medicare ACO Track 1+ Model (Track 1+ Model) is a time-limited CMS Innovation Center Model. An ACO must concurrently participate in Track 1 of the Shared Savings Program in order to be eligible to participate in the Track 1+ Model. An ACO participating in the Track 1+ Model remains subject to the Shared Savings Program quality performance standards and reporting requirements at 42 CFR Part 425 Subpart F which are relevant to the APM scoring standard under MIPS.
As such, for purposes of the APM scoring standard, MIPS eligible clinicians in the ACO Track 1+ Model are considered to be participating in Track 1 of the Shared Savings Program. (Table 3.1)20 20 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavings program/about.html
11 Table 3.1 Description of each track of the Shared Savings Program and the Track 1+ Model Track Financial Risk Arrangement Description 1 One-sided Track 1 ACOs do not assume shared losses if they do not lower growth in Medicare expenditures. Track 1+ Model Two-sided Track 1+ Model ACOs assume limited downside risk (less than Track 2 or Track 3). 2 Two-sided Track 2 ACOs may share in savings or repay Medicare losses depending on performance. Track 2 ACOs may share in a greater portion of savings than Track 1 ACOs. 3 Two-sided Track 3 ACOs may share in savings or repay Medicare losses depending on performance.
Track 3 ACOs take on the greatest amount of risk, but may share in the greatest portion of savings if successful.
Participating ACOs must report quality data to CMS after the close of every performance year to be eligible to share in any earned shared savings. Quality measures span four domains: patient/caregiver experience, care coordination/patient safety, preventive health, and at-risk populations.21 Although claims-based and administrative-data measures are required by the Shared Savings Program, only the ACO quality measures submitted via the CMS Web Interface and the CAHPS survey will be used for APM scoring standard purposes in 2018. In 2018, there are 14 ACO quality measures that are submitted via the CMS Web Interface (including one two-component diabetes measure) and one collected by patient survey (Table 3.2).
Note that measures may be removed from this list, but new measures will not be added for the 2018 performance year.
Table 3.2 Shared Savings Program and Next Generation ACO Model 2018 MIPS APM Measure List Measure Title Measure Description Submission Mechanism ACO-12 (CARE-1) Medical Reconciliation Post-Discharge Medication Reconciliation PostDischarge: The percentage of discharges from any inpatient facility (e.g., hospital, skilled CMS Web Interface 21 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavings program/program-guidance-andspecifications.html
12 Measure Title Measure Description Submission Mechanism nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing ongoing care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record.
This measure is reported as three rates stratified by age group: Reporting Criteria 1: 18–64 years of age Reporting Criteria 2: 65 years of age and older Total Rate: All patients 18 years of age and older ACO-13 (CARE-2) Falls: Screening for Future Fall Risk Falls: Screening for Future Fall Risk: Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.
CMS Web Interface ACO-14 (PREV-7) Preventive Care and Screening: Influenza Immunization Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization. CMS Web Interface ACO-15 (PREV-8) Pneumonia Vaccination Status for Older Adults Pneumococcal Vaccination Status for Older Adults: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.
13 Measure Title Measure Description Submission Mechanism ACO-16 (PREV-9) Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous 12 months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous 12 months of the current encounter.
Normal Parameters: Age 18 years and older BMI ≥18.5 and
14 Measure Title Measure Description Submission Mechanism appropriate standardized depression screening tool AND if positive, a followup plan is documented on the date of the positive screen. ACO-19 (PREV-6) Colorectal Cancer Screening Colorectal Cancer Screening: Percentage of patients 50–75 years of age who had appropriate screening for colorectal cancer. CMS Web Interface ACO-20 (PREV-5) Breast Cancer Screening Breast Cancer Screening: Percentage of women 50–74 years of age who had a mammogram to screen for breast cancer.
CMS Web Interface ACO-42 (PREV-13) Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Statin Therapy for the Prevention and Treatment of Cardiovascular Disease: Percentage of the following patients— all considered at high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period: ▪ Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR ▪ Adults aged ≥21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥190 mg/dL; OR ▪ Adults aged 40–75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70–189 mg/dL CMS Web Interface ACO-40 (MH- 1) Depression Remission at Twelve Months Depression Remission at Twelve Months: Patients aged 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) CMS Web Interface
15 Measure Title Measure Description Submission Mechanism score greater than nine who demonstrate remission at twelve months (+/− 30 days after an index visit) defined as a PHQ-9 score lower than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. Diabetes Composite ACO-27 (DM- 2) Diabetes: Hemoglobin A1c Poor Control Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%): Percentage of patients 18–75 years of age with diabetes who had HbA1c >9.0% during the measurement period. CMS Web Interface Diabetes Composite ACO-41 (DM- 7) Diabetes: Eye Exam Diabetes: Eye Exam: Percentage of patients 18–75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period.
CMS Web Interface ACO-28 (HTN-2) Hypertension (HTN): Controlling High Blood Pressure Controlling High Blood Pressure: Percentage of patients 18–85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (
16 Measure Title Measure Description Submission Mechanism period, and who had documentation of use of aspirin or another antiplatelet during the measurement period. ACO-1 through ACO- 7; ACO-34 Consumer Assessment of Healthcare Providers and Systems (CAHPS) for ACOs Clinician/Group CAHPS for MIPS Clinician/Group Survey: Summary Survey Measures may include ▪ Getting timely care, appointments, and information; ▪ How well providers communicate; ▪ Patient’s rating of provider; ▪ Access to specialists; ▪ Health promotion and education; ▪ Shared decision making; ▪ Health status and functional status; ▪ Courteous and helpful office staff; ▪ Care coordination; and ▪ Stewardship of patient resources.
Patient Survey 3.2 Next Generation ACO Building upon experience from the Pioneer ACO Model and the Medicare Shared Savings Program, the Next Generation ACO (NGACO) Model is an opportunity in accountable care— one that sets predictable financial targets, enables health care providers greater opportunities to coordinate care, and aims to attain the highest quality standards of care. The NGACO Model is an initiative for ACOs that are experienced in coordinating care for populations of patients that will allow participating ACOs to assume higher levels of financial risk and reward than are available under the Shared Savings Program.
The goal of the NGACO Model is to test whether strong financial incentives for ACOs, coupled with tools to support better patient engagement and care management, can lower Medicare expenditures and improve health outcomes for Original Medicare FFS beneficiaries.22 In the 2018 QPP performance period, the APM scoring methodology in the quality performance category for NGACO will follow the same measures and methodology used for the Shared Savings Program (Table 3.2). However, should a Next Generation ACO fail to report any Web Interface quality measure, the MIPS eligible clinicians participating in the ACO will receive a zero for the entire quality performance category.
3.3 Comprehensive Primary Care Plus Model 22 https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/
17 CPC+ is a national advanced primary care medical home model that aims to strengthen primary care through regionally based multipayer payment reform and care delivery transformation. CPC+ includes two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States. This model seeks to improve quality, access, and efficiency of primary care.
Practices in both tracks will make changes in the way they deliver care, centered on key Comprehensive Primary Care Functions: (1) Access and Continuity; (2) Care Management; (3) Comprehensiveness and Coordination; (4) Patient and Caregiver Engagement; and (5) Planned Care and Population Health.23 For the 2017 performance period, the CPC+ Model included 17 quality and utilization measures for performance-based incentive payment purposes. These 17 measures included 14 electronic Clinical Quality Measures (eCQMs), a subset of the Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey (CG CAHPS Survey), one inpatient hospital utilization measure, and one emergency department utilization measure.
CPC+ Practices were required to report data on 9 of the 14 eCQMs from the eCQM measure set. For scoring under the APM scoring standard in 2018, the updated quality and utilization measures are listed in Table 3.3. Note that measures may be removed from this list, but new measures will not be added for the 2018 performance period.
For eCQMs, there are several reporting options, including attestation through the secure CPC+ Practice Portal, or submission of a Quality Reporting Document Architecture (QRDA) Category III file to CMS electronically either via direct EHR or through a third-party data submission vendor. The CG CAHPS Survey will be conducted by CMS. The utilization measures are calculated by CMS based on claims data. Table 3.3 Comprehensive Primary Care Plus Model 2018 MIPS APM Measure List Measure Name NQFa /Quality Number (if applicable) Measure Description Submission Mechanism Controlling High Blood Pressure 0018 / 236 Percentage of patients 18–85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (
18 Measure Name NQFa /Quality Number (if applicable) Measure Description Submission Mechanism months prior to the measurement period Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 0059 / 001 Percentage of patients 18–75 years of age with diabetes who had HbA1c >9.0% during the measurement period QRDA III Dementia: Cognitive Assessment 2872 / 281 Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period QRDA III Falls: Screening for Future Fall Risk 0101 / 318 A) Screening for Future Fall Risk: Patients who were screened for future fall risk at last once within 12 months B) Multifactorial Falls Risk Assessment: Patients at risk of future fall who had a multifactorial risk assessment for falls completed within 12 months C) Plan of Care to Prevent Future Falls: Patients at risk of future fall with a plan of care for falls prevention documented within 12 months.
QRDA III Initiation and Engagement of Alcohol and Other Drug Dependence Treatment 0004 / 305 Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported: a. Percentage of patients who initiated treatment within 14 days of the diagnosis.
b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit. QRDA III Closing the Referral Loop: Receipt of Specialist Report N/A / 374 Percentage of patients with referrals, regardless of age, for which the referring provider receives a report QRDA III
19 Measure Name NQFa /Quality Number (if applicable) Measure Description Submission Mechanism from the provider to whom the patient was referred Cervical Cancer Screening 0032 / 309 Percentage of women 21–64 years of age, who were screened for cervical cancer using either of the following criteria.
Women aged 21–64 who had cervical cytology performed every 3 years ▪ Women aged 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years QRDA III Colorectal Cancer Screening 0034 / 113 Percentage of patients 50–75 years of age who had appropriate screening for colorectal cancer QRDA III Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 0028 / 226 Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months and who received cessation counseling intervention if identified as a tobacco user QRDA III Breast Cancer Screening 2372 / 112 Percentage of women 50–74 years of age who had a mammogram to screen for breast cancer QRDA III Preventive Care and Screening: Influenza Immunization 0041 / 110 Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization QRDA III Pneumonia Vaccination Status for Older Adults 0043 / 111 Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine QRDA III Diabetes: Medical Attention for Nephropathy 0062 / 119 Percentage of patients 18–75 years of age with diabetes who had a nephropathy screening test or QRDA III
20 Measure Name NQFa /Quality Number (if applicable) Measure Description Submission Mechanism evidence of nephropathy during the measurement period Ischemic Vascular Disease (IVD): Use of Aspirin or Another 0068 / 204 Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period QRDA III Preventive Care and Screening: Screening for Depression and Follow-Up Plan 0418 / 134 Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen QRDA III Statin Therapy for the Prevention and Treatment of Cardiovascular Disease N/A / 438 Percentage of the following patients— all considered at high risk of cardiovascular events— who were prescribed or were on statin therapy during the measurement period: ▪ Adults aged ≥21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR ▪ Adults aged ≥21 years who have ever had a fasting or direct lowdensity lipoprotein cholesterol (LDLC) level ≥190 mg/dL or were previously diagnosed with or QRDA III
21 Measure Name NQFa /Quality Number (if applicable) Measure Description Submission Mechanism currently have an active diagnosis of familial or pure hypercholesterolemia; OR ▪ Adults aged 40–75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70–189 mg/dL Inpatient Hospital Utilization (IHU) N/A For members 18 years of age and older, the risk-adjusted ratio of observed to expected acute inpatient discharges during the measurement year reported by Surgery, Medicine, and Total N/A: Claimsbased measure Emergency Department Utilization (EDU) N/A For members 18 years of age and older, the risk-adjusted ratio of observed to expected emergency department (ED) visits during the measurement year N/A: Claimsbased measure CAHPS CPC+- specific; different than CAHPS for MIPS CG-CAHPS Survey 3.0 Patient Survey a NQF = National Quality Forum N/A = not applicable.
CPC+ Practices are required to submit data on only 9 measures out of the list of eCQMs. CMS will only use the best performing 9 measures for purposes of the APM scoring standard, provided the measure set meets minimum case size and has a benchmark available, should Practices submit beyond the required 9 measures.
The CPC+ Practices’ performance on eCQMs are assessed against absolute performance thresholds.. All eCQMs will have benchmarks; the benchmarks for 2018 will be available to CPC+ Practices prior to the performance period. The CAHPS benchmarks are calculated from the Agency for Healthcare Research and Quality (AHRQ) CAHPS database using the CAHPS Analysis Program. 3.4 Oncology Care Model The OCM aims to provide higher-quality, more coordinated oncology care at the same or lower cost to Medicare. Under OCM, physician group practices may receive performance-based
22 payments for episodes of care surrounding chemotherapy administration to cancer patients.
One-sided risk and two-sided risk arrangements are available in the Model. The practices participating in OCM have committed to providing enhanced services to Medicare beneficiaries such as documenting a care plan, providing the core functions of patient navigation, and using therapies consistent with nationally recognized treatment guidelines for care.24 The OCM collects results from 12 quality measures that are tied to payment, including one composite measure. These include both process and outcome measures, which are collected via three data sources: claims, reported by the practice, and a survey measure (Patient Reported Experience).
OCM practices submit the majority of the measures using a registry. However, for the 2018 MIPS performance year, CMS will use the three claims-based measures and the one patient survey measure available from “Performance Period 3”25 of OCM for APM scoring standard purposes (see Table 3.4 for details). Note that measures may be removed from this list, but new measures will not be added for the 2018 MIPS performance year. Table 3.4 Oncology Care Model 2018 MIPS APM Measure List Measure Number in OCM Measure Name NQF/ Quality Number (if applicable) Measure Description Submission Mechanism OCM-1 All-cause admissions N/A Risk-adjusted proportion of patients with all-cause hospital admissions within the 6-month episode N/A: Claimsbased measure OCM-2 All-cause emergency department visits or observation stays N/A Risk-adjusted proportion of patients with all-cause emergency department visits or observation stays that did not result in a hospital admission within the 6-month episode N/A: Claimsbased measure OCM-3 Patients admitted to hospice N/A Proportion of patients who died who were admitted to hospice for 3 days or more N/A: Claimsbased measure 24 https://innovation.cms.gov/initiatives/oncology-care/ 25 Performance Period 3 covers the 6-month oncology care episodes that ends January 1, 2018, through June 30, 2018.
23 Measure Number in OCM Measure Name NQF/ Quality Number (if applicable) Measure Description Submission Mechanism OCM-6 Patient-Reported Experience of Care N/A Patient-Reported Experience of Care Patient Survey N/A = not applicable 3.5 Comprehensive End-Stage Renal Disease Care Model The CEC Model is designed to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with ESRD. The Model aims to test accountable care concepts for ESRD beneficiaries. In the CEC Model, dialysis clinics, nephrologists, and other providers join together to create an APM Entity, known as an ESRD Seamless Care Organization (ESCO) to coordinate care for matched beneficiaries.
ESCOs are accountable for clinical quality outcomes and financial outcomes.26 The CEC Model includes separate financial arrangements for large and small dialysis organizations. Large Dialysis Organizations (LDOs), which have 200 or more dialysis facilities, will be eligible to receive shared savings payments. These LDOs will also be liable for shared losses and will have higher overall levels of risk compared with their smaller counterparts. NonLDOs include chains with fewer than 200 dialysis facilities, independent dialysis facilities, and hospital-based dialysis facilities. Non-LDOs will have the option of participating in a one-sided risk track where they will be able to receive shared savings payments but will not be liable for payment of shared losses, or participating in a track with the opportunity for greater shared savings and the potential for shared losses.
The one-sided risk track is offered in recognition of non-LDOs more-limited resources.27 The CEC Model has 21 quality measures that are tied to payment, however only 16 are eligible for scoring under the APM scoring standard in 2018. Measures are either process or outcome measures and there are 4 data sources for the measures collected in the CEC measures set— CMS ESRD Quality Incentive Program (QIP) results, claims measures, hybrid measures, and a survey measure (the Kidney Disease Quality of Life Survey). The ESCO receives credit under the APM for complete reporting on all measures (see below).
ESCOs submit some measures to CEC through the Quality Measures Assessment Tool (QMAT), and other measures (e.g., CAHPS) come from Center for Clinical Standards and Quality measure results (see Table 3.5). Note that measures may be removed from this list, but new measures will not be added for the 2018 performance year. 26 https://innovation.cms.gov/initiatives/comprehensive-esrd-care/ 27 https://innovation.cms.gov/initiatives/comprehensive-esrd-care/
24 Benchmarks will be used for all measures. Given the CEC timeline, it may be likely that the CEC Model will not have participants’ quality information collected in time for APM scoring in 2019 for the 2018 performance period.
In this case, eligible clinicians in these CEC APM entities will have their quality performance category reweighted to zero percent. Table 3.5 Comprehensive ESRD Care Model 2018 MIPS APM measure list Measure Name NQF/ Quality Number (if applicable) Measure Description Submission Mechanism ESCO Standardized Mortality Ratio 0369/154 This measure is calculated as a ratio but can also be expressed as a rate. N/A: Claimsbased measure Falls: Screening, Risk Assessment and Plan of Care to Prevent Future Falls 0101/154 A) Screening for Future Fall Risk: Patients who were screened for future fall risk at last once within 12 months B) Multifactorial Falls Risk Assessment: Patients at risk of future fall who had a multifactorial risk assessment for falls completed within 12 months C) Plan of Care to Prevent Future Falls: Patients at risk of future fall with a plan of care for falls prevention documented within 12 months.
QMAT Advance Care Plan 0326/47 Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan QMAT In-Center Hemodialysis (ICH)- CAHPS: Nephrologists’ 0258
Summary/Survey Measures may include:
Getting timely care, appointments, and information; Patient Survey
25 Measure Name NQF/ Quality Number (if applicable) Measure Description Submission Mechanism Communication and Caring
Patients’ rating of provider;
Health status and functional status;
Helping you to take medications as directed; and
ICH-CAHPS: Rating of Dialysis Center 0258 Comparison of services and quality of care that dialysis facilities provide from the perspective of ESRD patients receiving in-center hemodialysis care. Patients will assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease. Patient Survey ICH-CAHPS: Quality of Dialysis Center Care and Operations 0258 Comparison of services and quality of care that dialysis facilities provide from the perspective of ESRD patients receiving in-center hemodialysis care.
Patients will assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and Patient Survey
26 Measure Name NQF/ Quality Number (if applicable) Measure Description Submission Mechanism information sharing about their disease. ICH-CAHPS: Providing Information to Patients 0258 Comparison of services and quality of care that dialysis facilities provide from the perspective of ESRD patients receiving in-center hemodialysis care. Patients will assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease.
Patient Survey ICH-CAHPS: Rating of Kidney Doctors 0258 Comparison of services and quality of care that dialysis facilities provide from the perspective of ESRD patients receiving in-center hemodialysis care.
Patients will assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease. Patient Survey ICH-CAHPS: Rating of Dialysis Center Staff ICH-CAHPS: Rating of Dialysis Center 0258 Comparison of services and quality of care that dialysis facilities provide from the perspective of ESRD patients receiving in-center hemodialysis care. Patients will assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease.
Patient Survey Medication Reconciliation Post Discharge 0554 The percentage of discharges from any inpatient facility (e.g., hospital, skilled nursing facility, or QMAT
27 Measure Name NQF/ Quality Number (if applicable) Measure Description Submission Mechanism rehabilitation facility) for patients 18 years of age and older seen within 30 days following the discharge in the office by the physicians, prescribing practitioner, registered nurse, or clinical pharmacist providing ongoing care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record.
This measure is reported as three rates stratified by age group: ▪ Reporting Criteria 1: 18–64 years of age ▪ Reporting Criteria 2: 65 years and older ▪ Total Rate: All patients 18 years of age and older Diabetes Care: Eye Exam 0055/117 Percentage of patients 18–75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period QMAT Diabetes Care: Foot Exam 0056/163 Percentage of patients 18–75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the previous measurement year QMAT Influenza Immunization for the ESRD Population 0041/110, 0226 Percentage of patients aged 6 months and older seen for a visit between July 1 and March 31 who received an influenza immunization QMAT
28 Measure Name NQF/ Quality Number (if applicable) Measure Description Submission Mechanism OR who reported previous receipt of an influenza immunization Pneumococcal Vaccination Status 0043/111 Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine QMAT Screening for Clinical Depression and Follow-Up Plan 0418/134 Percentage of patients aged 12 and older screened for depression on the date of the encounter and using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen QMAT Tobacco Use: Screening and Cessation Intervention 0028/226 Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user QMAT N/A = not applicable.
Section 4: APM Scoring Standard for the Quality Performance Category In the 2018 Quality Payment Program Final Rule, the APM scoring standard for the quality performance category is broken out separately for (1) APM Entities that submit quality data using the CMS Web Interface; and (2) Other MIPS APM Entities that do not use the CMS Web Interface.28 Regardless of this distinction, the APM scoring standard in this category for MIPS APMs comprises three scoring concepts: (1) quality measures achievement points, scored according to performance against a benchmark; (2) quality measures bonus points; and (3) quality improvement score if applicable.
4.1 Quality Measures Achievement Points 4.1.1 CMS Web Interface Reporters The quality performance category score for a MIPS performance period is calculated for the MIPS eligible clinicians identified on a Participation List for the MIPS APM using the data 28 42 C.F.R. §414.1370 2017
2019 Merit-based Incentive Payment System (MIPS) Cost Performance Category Fact Sheet →