Quality Reporting Under MIPS: 7 Key Questions

Medicare’s Merit-based Incentive Payment System, or MIPS, ties Medicare Part B payments to how well physicians and other eligible clinicians perform in four categories: quality, improvement activities, advancing health information and costs. The biggest emphasis, however, is on quality. In 2017, which is the first performance year, 60 percent of payment is tied to how well providers perform on quality metrics.

Hospitals and health systems that want to potentially receive a payment bonus in 2019 need to select six quality metrics and begin tracking them by Oct. 2, which is the last day to start collecting data to meet 2017 reporting deadlines.

The Centers for Medicare & Medicaid Services provides hundreds of metrics to choose from on the Quality Payment Program website, along with submission guidelines. Akin Demehin, director of policy at the American Hospital Association, suggests that leaders consider the following questions as they sort through their MIPS quality reporting options:

What are the organization’s quality priorities? “What hospitals really hope to do is to identify those quality measures that align with their broader quality priorities, rather than just reporting a measure for the sake of reporting it,” Demehin says.

What is the clinician’s affiliation? Hospitals and health systems only need to report quality metrics for their employed physicians and other eligible clinicians. This comes down to tax identification numbers. Generally, hospitals and health systems employing clinicians need to submit under MIPS for each of their tax IDs. Some organizations may have a single tax ID that encompasses all of its hospitals and employed providers, while others may have separate tax IDs for some employed provider groups.

While hospitals may want to help affiliated providers prepare for MIPS, those providers need to submit under their own tax IDs.

Did clinicians participate in the Physician Quality Reporting System, or PQRS? “If a hospital is already reporting quality metrics via PQRS, then it will have a head start in pivoting to MIPS,” says Demehin.

PQRS was a precursor program to MIPS that gave payment bonuses to providers that reported quality data to Medicare. MIPS includes many of the PQRS quality metrics and enables hospitals to submit quality data via the same reporting mechanisms. Some hospitals may choose to continue reporting on some of the same PQRS metrics for the first year of MIPS.

What specialties are most applicable? CMS requires providers to only report “applicable” quality metrics that best reflect the type of general or specialty care provided. To help providers identify applicable metrics, the MIPS measures have been divided into 30 specialty sets, including hospitalists, cardiologists and pediatricians.

Hospitals might start with a specialty measure set that applies to about 50 percent of their patients and then double-check the specifications of all measures to ensure they are applicable. Each quality metric has specific requirements.

For instance, an acute care hospital with a trauma center and multispecialty center might pick measures from the hospitalist and emergency medicine sets. An employed multispecialty practice that mostly sees patients with heart problems might focus on cardiology measures.

“It’s OK if the metrics do not relate to some of the specialists in a group,” Demehin says. “CMS recognizes that finding a measure that applies to every single clinician is tough, particularly in multispecialty practices participating in group reporting.”

What high-priority measure(s) to submit? MIPS encourages providers to report at least one outcome measure that gauges how well patients responded to the care provided. Examples include high blood pressure control and depression remission.

CMS, however, recognizes that not all specialties have valid outcome measures. When that is the case, providers can choose a process measure that is identified as “high-priority.” Of the almost 300 MIPS measures, about half are high-priority. These measures focus on accepted aspects of quality, including effectiveness, coordination and communication, patient experience, safety, and efficiency.

Providers that report on more than one high-priority measure will get extra points under MIPS.

Which data submission mechanism to use? Another factor that affects which metrics to report is the data submission mechanism a hospital decides to use. In 2017, CMS is requiring providers to submit all quality data via the same mechanism. So hospitals will want to determine which mechanism they are going to use before deciding on which metrics to report. Not all metrics can be reported via all mechanisms.

MIPS has six reporting mechanisms, but only four apply to providers reporting as a group, which includes hospitals:

Qualified registries, which are CMS-approved entities that collect MIPS data from providers for submission to CMS.
Qualified clinical data registries, or QCDRs, allow hospitals to submit additional CMS-approved, specialty-specific quality measures that are not included on the official MIPS list of quality metrics.
Electronic health record reporting, which involves reporting six of the 53 CMS-recognized electronic clinical quality metrics, or eCQMs.
CMS web interface, which requires submission of quality metrics from a group of mostly primary care and population health measures.

In addition, hospitals can use a vendor to submit patient experience survey results from the Consumer Assessment of Healthcare Providers and Systems.

Hospitals that report eCQMs via their EHRs will receive extra points under MIPS.

How might everything change in 2018 and beyond? MIPS specifics will change from year to year as the program matures. For instance, CMS’ proposed 2018 rule for the Quality Payment Program raises the possibility of facility-based reporting for hospitalists and other clinicians who mostly care for patients in the hospital. This would allow these clinicians to have their scores tied to their hospital’s performance in Medicare's Hospital Value-Based Purchasing Program.