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Merit-Based Incentive Payment System (MIPS)

Resource GuideNovember 3, 2016

CONTENTS

Section 1. MIPS and Who It Applies To .....................................................................................2

Section 2. Preparation Checklist ................................................................................................4

Section 3. Quality Performance Category (60%) ....................................................................7

Section 4. Cost Performance Category (0%) ........................................................................ 13

Section 5. Advancing Care Information Performance Category (25%) .......................... 14

Section 6. Improvement Activities Performance Category (15%) ................................... 17

Section 7. MIPS Reporting Mechanisms................................................................................ 20

Section 8. Additional Resources .............................................................................................. 20

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MIPS and Who It Applies To SECTION 1

The Medicare and CHIP Reauthorization Act (MACRA) of 2015 created sweeping reforms to reimbursement to providers under Medicare Part B and establishes a new Quality Payment Program. The Quality Payment Program outlines two pathways for payment for providers who participate in Medicare Part B: Advanced Alternative Payment Models and the Merit-Based Incentive Payment System (MIPS). The vast majority of providers will be reimbursed under MIPS in 2017. This MIPS Resource Guide includes a readiness checklist, details related to the performance reporting categories, and information on the specific reporting options available to providers.

All of the information provided in this MIPS Resource Guide is based on detail in final rulemaking issued by the Centers for Medicare and Medicaid Services on October 14, 2016.

About MIPSMIPS collapses three existing quality reporting programs into one, while adding a fourth category:

• The Physician Quality Reporting System (PQRS) becomes Quality under MIPS, and assesses eligible clinicians on their performance on at least six quality measures

• The Value-based Payment Modifier Program (VM) becomes Cost under MIPS, and compares costs to treat similar care episodes and clinical condition groups across practices

• The Medicare Electronic Health Record (EHR) incentive program becomes Advancing Care Information under MIPS, and retains an emphasis on interoperability and information exchange

• A brand-new reporting area is Improvement Activities, which rewards practices that engage in quality improvement activities, including for their Medicaid and other non-Medicare patient populations

Each of the four categories listed above are weighted and collectively form a final score from 0-100. CMS will set a performance threshold every year and compare eligible clinicians’ and group’s scores to the threshold to determine payment adjustments

MIPS-Eligible CliniciansEligible clinicians during the 2017 reporting year include physicians (including psychiatrists), nurse practitioners, physician assistants, clinical nurse specialists and nurse anesthetists who bill Medicare Part B using the physician fee schedule.

In 2017, MIPS does NOT apply to:• Clinical psychologists & licensed clinical social

workers (LCSWs)• First-year Medicare providers• Qualifying Advanced APM clinicians• Hospitals and facilities (e.g., skilled nursing

facilities) that do not bill medicare using the Physician Fee Schedule

• Clinicians who fall beneath CMS’s low-volume threshold, who serve fewer than 100 Medicare recipients OR bill Medicare $30,000 or less per year

• Clinicians and groups who are not paid under the Physician Fee Schedule (e.g., FQHCs and partial hospitalization programs); MIPS also does not apply to Managed Care payments

Although they are not considered eligible in 2017, the final rule states that additional clinicians, including psychologists and LCSWs, may be eligible to report to MIPS in 2019

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Performance CategoriesCMS will score each MIPS eligible clinician or group according to four performance categories in 2017. Each category will be weighted differently:

Reporting Options: “Pick Your Pace”In September 2016, CMS announced that MIPS eligible clinicians will have three reporting options to avoid a negative payment adjustment in 2019:

• Option 1: Test the Quality Payment Program. As long as you submit some data via MIPS, including data from after January 1, 2017, you will avoid a negative payment adjustment. This option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019.

MIPS Scoring and 2019 Payment Adjustments

CMS will use these weighted scores to calculate a final score between 0-100. CMS will use this score to determine positive, neutral and negative payment adjustments in 2019. Payment adjustments are expected to increase every year, from +/- 4.0% in 2019 to +/-9.0% in 2022.

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• Option 2: Participate for part of the calendar year. You may choose to submit MIPS data for at least 90 consecutive days in 2017. This means your first performance period could begin later than January 1, 2017 and your practice could still qualify for a small positive payment adjustment.

• Option 3: Participate for the full calendar year. For practices that are ready to go on January 1, 2017, you can choose to submit MIPS data information for the full calendar year. This means your first performance period would begin on January 1, 2017.

Preparation ChecklistSECTION 2

Start NOW and Keep Going

1 Determine if you’re eligible for MIPS.

• As an individual clinician, are you below the low-volume threshold of seeing 100 or fewer Medicare patients OR billing Medicare $30,000 or less per year?

• If you are part of a group practice, does the group fall beneath the low-volume threshold of seeing 100 or fewer Medicare patients OR billing Medicare $30,000 or less per year?

• Is 2017 your first year billing Medicare Part B using the Physician Fee Schedule?

• Do you bill for items and services furnished by a MIPS eligible clinician only under a faculty-based methodology?

If the answer is yes to any of these questions, MIPS does NOT apply to you in 2017. CMS will contact clinicians who participate in Medicare Part B in December 2016 to confirm their eligibility. If you are not eligible, you may still choose to report voluntarily and receive feedback on your performance. If

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If MIPS does NOT apply to you, learn as much as you can anyway.

Value-based payments are an important goal for all the major payers, not just Medicare. To meet these demands, all behavioral health organizations will need to cultivate an organizational culture that embraces change, and develop the infrastructure needed to measure progress, demonstrate value and improve health outcomes.

Educate your team.

Successful participation in the Quality Payment Program will depend on everyone on your team. Share information with practice administrators, clinicians and support staff. Make sure they understand how CMS will measure performance, and how MIPS may affect Medicare reimbursements starting in 2019.

(See http://www.thenationalcouncil.org/macra/ for helpful resources)

Connect with the CMS-funded Transforming Clinical Practice Initiative (TCPI).

TCPI supports 29 Practice Transformation Networks and Support and Alignment Networks across the country, which provide free resources and technical support to help practices improve quality of care, reduce costs, and prepare for value-based payment arrangements. Visit http://www.healthcarecommunities.org/ or contact the National Council to learn more.

you voluntarily report, you will receive feedback on your performance, but you will not be subject to payment adjustments in 2019.

Quality

6 If your practice currently participates in PQRS…

• What type of feedback have you received on your prior performance? (If you have not already received feedback via your Quality and Resource Use Report (QRUR), refer to CMS guidance here).

• What can you do to improve your performance? Remember: Unlike PQRS, MIPS is NOT a pay-for-reporting mechanism. The data you submit for each quality measure will be compared to benchmarks in order to determine your Quality score. The baseline period for deriving benchmarks will be two years prior to the performance year, which will enable CMS to publish measure benchmarks prior to the start of the relevant performance year.

• Review the MIPS quality measures, including the Behavioral/Mental Health measure set. Which six

Stay Up-to-Date

CMS released the final rule in October, but has requested comments on certain components that may affect eligible behavioral health care providers. Also, Quality Payment Program reporting requirements will change over time. The National Council can help you stay informed and support you to meet these requirements every year. Subscribe to the National Council’s Capitol Connector blog and check out our website’s MACRA resources.

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7 If your practice does NOT currently participate in PQRS…

• Review the MIPS quality measures, including the Behavioral/Mental Health measure set. • Which quality measures would make the most sense for your practice to report on in 2017? • Work with your staff to determine how you will incorporate data collection into current workflows. • Start collecting data and measuring performance on 1-2 of your chosen measures to start.

Determine your baseline so you know how much you will need to improve your performance once CMS determines performance thresholds for each measure.

If your practice does NOT participate in PQRS in 2016, you may receive a negative payment adjustment in 2018.

Cost

8 Understand your cost of care.

If your practice participated in PQRS last year, review your Quality and Resource Use Report (QRUR). This report explains your performance in terms of cost and quality so you can prioritize areas for improvement. (If you have not received your QRUR, please refer to CMS’s guidance on how to obtain it).

Although this category will not count toward your final score in 2017, CMS will still provide feedback based on your 2017 performance. The weight of this category will also increase over time, counting for 30% of your final score by the 2020 performance year.

CMS will assess performance in the Cost performance category using measures based on administrative Medicare claims data. Therefore, MIPS eligible clinicians are not required to independently report for this category.

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If you have an EHR, make sure it is certified EHR technology (CEHRT)

A well-designed CEHRT can help you fulfill current quality reporting requirements and provide real-time summaries of your progress on quality measures. If you have an EHR, determine whether it is 2014- or 2015- edition certified—the version will determine which Advancing Care Information measures you will choose to report in 2017.

If you do NOT have an EHR, use a qualified clinical data registry.

CMS defines a qualified clinical data registries (QCDR) as an approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to improve the quality of patient care. They can streamline reporting, help you identify high-risk populations, and make targeted improvements in clinical practice. CMS approved this list of QCDRs for reporting in 2016.

Advancing Care Information

quality measures would make the most sense for your practice to report on in 2017? (Don’t forget to identify at least one outcome/high-priority measure).

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11 Review the list of MIPS Improvement Activities (see page 18).• Which improvement activities do you currently have in place? How many points would they

earn for your practice?• Would any of your current improvement activities need to be modified to comply with CMS’s

definition?• If your organization is currently not engaging in any improvement activities, or is not engaging

in enough activities to earn a full 40 points, which activities would be the easiest to implement, and make the most sense for your practice?

Small practices and those located in rural or Health Professional Shortage Areas will only need to attest to completing two activities in this category to earn full credit.

Improvement Activities

12 Subscribe to the BHive and Capitol Connector to stay abreast of upcoming practice improvement projects offered by the National Council. Contact Communications@TheNationalCouncil.org to sign up!

Quality Performance Category (60%) SECTION 3

For the 2017 reporting year, the Quality performance category is worth 60% of the MIPS final score. An adaptation of the PQRS program, the MIPS Quality category requires clinicians to choose six measures to report that best reflect their practice. At least one measure must be an outcome or other high-priority measure.

Clinicians may report measures from the Mental/Behavioral Health Specialty Set to fulfill this requirement (see Table 1), which includes 25 measures. In 2017, clinicians who do not have enough measures to select at least six should choose and report on all of the measures that apply to them.

Clinicians may earn bonus points in this category for measures gathered and reported electronically via a qualified clinical data registry, CMS Web Interface (groups of 25+ clinicians only) or CEHRT mechanisms.

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Measure Definition Type High Priority?

Data Submission

MethodADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication

Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.

Process No EHR

Adherence to Antipsychotic Medications for Individuals with Schizophrenia

Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)

Intermediate Outcome

Yes Registry

Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions

Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition

Process Yes Registry

Table 1. MACRA Quality Payment Program Behavioral Health Specialty Set Quality Measures

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Anti-Depressant Medication Management

Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).

Process No EHR

Care Plan 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

Process Yes Claims

Registry

Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk

Process Yes EHR

Closing the Referral Loop: Receipt of Specialist Report

Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

Process Yes EHR

Dementia: Counseling Regarding Safety Concerns

Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period

Process Yes Registry

Dementia: Caregiver Education & Support

Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional resources for support within a 12 month period

Process Yes Registry

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Dementia: Cognitive Assessment

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

Process No EHR

Dementia: Functional Status Assessment

Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period

Process No Registry

Dementia: Management of Neuropsychiatric Symptoms

Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period

Process No Registry

Dementia: Neuropsychiatric Symptom Assessment

Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period

Process No Registry

Depression Remission at Six Months

Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator

Outcome Yes Registry

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Depression Remission at Twelve Months

Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.

Outcome Yes EHR

CMS Web Interface

Registry

Depression Utilization of the PHQ-9 Tool

Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a 4-month period in which there was a qualifying visit

Process No EHR

Documentation of Current Medications in the Medical Record

Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.

Process Yes Claims

EHR

Registry

Elder Maltreatment Screen and Follow-Up Plan

Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen.

Process Yes Claims

Registry

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Follow-Up After Hospitalization for Mental Illness (FUH)

The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner.

Two rates are reported:

The percentage of discharges for which the patient received follow-up within 30 days of discharge.

The percentage of discharges for which the patient received follow-up within 7 days of discharge

Process Yes Registry

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 six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2

Process No Claims

EHR

CMS Web Interface

Registry

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

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

Process No Claims

EHR

CMS Web Interface

Registry

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

Process No Claims

EHR

Registry

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Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user

Process No Registry

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

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

Process No Claims

EHR

CMS Web Interface

Registry

Tobacco Use and Help with Quitting Among Adolescents

The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

Process No Registry

Cost Category (0%)SECTION 4

In 2017, the Cost Category is worth 0% of the MIPS final score. An adaptation of the Value-based Modifier payment program, this category compares one MIPS eligible clinician’s Medicare Part B charges for care episodes or clinical condition groups against other providers’ charges. A clinician or group practice’s Cost score is based on a CMS claims analysis and does not require independent reporting. Although this category will not factor into eligible clinicians’ 2017 final score, CMS will provide feedback on 2017 performance. The category’s weight will increase over time, reaching 30% by the 2020 performance year.

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Advancing Care Information Performance Category (25%)

SECTION 5

In 2017, the Advancing Care Information Performance Category is worth 25% of the MIPS final score. Under MIPS, the Advancing Care Information performance category replaces the Medicare EHR Incentive Program, often called “Meaningful Use.”

The Advancing Care Information score includes a base score and performance score, and the potential to earn bonus points. Eligible clinicians and groups must earn all 50 available base score points in order to get credit for this category and have the potential to earn additional performance score and bonus points. Although a MIPS eligible clinician or group may earn up to 155 points, the maximum score in this category is 100.

How you report in this category depends on whether your CEHRT is 2014- or 2015 edition certified. CMS has developed two different measure sets: the Advancing Care Information Objectives and Measures Set (see Table 2), and the 2017 Advancing Care Information Transition Objectives and Measures Set (see Table 3). If your CEHRT is certified to the 2015 edition, you can either report using the Advancing Care Information Objectives and Measures Set, or a combination of both measure sets. If your CEHRT is certified to the 2014 edition, you can either report using the 2017 Advancing Care Information Transition Objectives and Measures Set or a combination of both measure sets. If a MIPS eligible clinician switches from 2014 Edition to 2015 Edition CEHRT during the performance period, the data collected for the base and performance score measures should be combined from both the 2014 and 2015 Edition of CEHRT.

BASE SCORE (50%)MIPS eligible clinicians and groups must report on all five of the required measures in the base score to earn any points in the Advancing Care Information performance category: they must report a one in the numerator for numerator/denominator measures, and a “yes” for yes/no measures.

Advancing Care Information Transition Objective

Advancing Care Information Transition Measure*

Required/Not Required for Base Score

(50%)

Performance Score

(Up to 90%)

Reporting Requirement

Protect Patient Health Information

Security Risk Analysis

Required 0 Yes/No Statement

Electronic Prescribing

e-Prescribing Required 0 Numerator/Denominator

Patient Electronic Access

Provide Patient Access

Required Up to 10% Numerator/Denominator

Patient-Specific Education

Not Required Up to 10% Numerator/Denominator

Table 2. Advancing Care Information Objectives and Measures

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Advancing Care Information Transition Objective

Advancing Care Information Transition Measure*

Required/Not Required for Base Score

(50%)

Performance Score

(Up to 90%)

Reporting Requirement

Coordination of Care Through Patient Engagement

View, Download, or Transmit (VDT)

Not Required Up to 10% Numerator/Denominator

Secure Messaging Not Required Up to 10% Numerator/Denominator

Patient-Generated Health Data

Not Required Up to 10% Numerator/Denominator

Health Information Exchange

Send a Summary of Care

Required Up to 10% Numerator/Denominator

Request/Accept Summary of Care

Required Up to 10% Numerator/Denominator

Clinical Information Reconciliation

Not Required Up to 10% Numerator/Denominator

Public Health and Clinical Data Registry Reporting

Immunization Registry Reporting

Not Required 0 or 10% Yes/No Statement

Syndromic Surveillance Reporting

Not Required Bonus Yes/No Statement

Electronic Case Reporting

Not Required Bonus Yes/No Statement

Public Health Registry Reporting

Not Required Bonus Yes/No Statement

Clinical Data Registry Reporting

Not Required Bonus Yes/No Statement

Bonus (up to 15%)Report to one or more additional public health and clinical data registries beyond the Immunization Registry Reporting measure

5% bonus Yes/No Statement Report to one or more additional public health and clinical data registries beyond the Immunization Registry Reporting measure

5% bonus

Report improvement activities using CEHRT

10% bonus Yes/No Statement Report improvement activities using CEHRT

10% bonus

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Table 3. 2017 Advancing Care Information Transition Objectives and Measures

2017 Advancing Care

Information Transition Objective

(2017 Only)

2017 Advancing Care

Information Transition Measure*

(2017 Only)

Required/Not Required for Base Score

(50%)

Performance Score

(Up to 90%)

Reporting Requirement

Protect Patient Health Information

Security Risk Analysis

Required 0 Yes/No Statement

Electronic Prescribing

E-Prescribing Required 0 Numerator/Denominator

Patient Electronic Access

Provide Patient Access

Required Up to 20% Numerator/Denominator

View, Download, or Transmit (VDT)

Not Required Up to 10% Numerator/Denominator

Patient-Specific Education

Patient-Specific Education

Not Required Up to 10% Numerator/Denominator

Secure Messaging Secure Messaging Not Required Up to 10% Numerator/Denominator

Health Information Exchange

Health Information Exchange

Required Up to 20% Numerator/Denominator

Medication Reconciliation

Medication Reconciliation

Not Required Up to 10% Numerator/Denominator

Public Health Reporting

Immunization Registry Reporting

Not Required 0 or 10% Yes/No Statement

Syndromic Surveillance Reporting

Not Required Bonus Yes/No Statement

Specialized Registry Reporting

Not Required Bonus Yes/No Statement

Bonus (up to 15%)

Report to one or more addition-al public health and clinical data registries beyond the Immunization Registry Reporting measure

5% bonus Yes/No Statement Report to one or more addition-al public health and clinical data registries beyond the Immunization Registry Reporting measure

5% bonus

Report improve-ment activities using CEHRT

10% bonus Yes/No Statement Report improve-ment activities using CEHRT

10% bonus

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PERFORMANCE SCORE (up to 90%)The Advancing Care Information performance score builds upon the base score and is based on a MIPS eligible clinician’s performance rate for each measure reported for the performance score (calculated using the numerator/denominator). A performance rate of 1-10 percent would earn 1 percentage point, a performance rate of 11-20 percent would earn 2 percentage points and so on. With nine measures included in the performance score, a MIPS eligible clinician or group has the ability to earn up to 90 percentage points if they report all measures in the performance score.

To determine the MIPS eligible clinician’s overall Advancing Care Information performance category score, CMS will use the sum of the base score, performance score, and potential bonus points. If the sum of the MIPS eligible clinician or group’s base score (50 percent), performance score (out of a possible 90 percent), and bonus points are greater than 100 percent, CMS will apply an Advancing Care Information performance category score of 100 percent.

TOTAL SCORE (100%)

SECTION 6

Improvement Activities Performance Category (15%)

In 2017, the Improvement Activities Performance Category is worth 15% of the MIPS final score. This new performance category enables clinicians to choose from a list of more than 90 quality improvement activities and determine which ones best suit their practice. Activities fall into nine categories (see below). MIPS eligible clinicians may choose activities within the Integrated Behavioral and Mental Health category (see Table 4) or other activities that apply to behavioral health care, including participation in CMS’s four-year Transforming Clinical Practice Initiative.

Expanded Practice Access

Patient Safety and Practice Assessment

Care CoordinationParticipation in an APM,

including a medical home model

Integrated Behavioral and Mental Health

Emergency Preparedness and

Response

Population Management

Achieving Health Equity

Beneficiary Engagement

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In order to earn full credit in this category, clinicians or groups must perform selected activities for at least 90 consecutive days. They must attest each activity performed by selecting “yes” during reporting through a qualified registry, EHR, Qualified Clinical Data Registry, or the CMS Web Interface (groups of 25+ only).

Most clinicians must attest to completing up to four activities. “High” weighted activities are worth 20 points, while “Medium” activities are worth 10 points.

Clinicians who work in small, rural or HPSA practices can earn full credit by attesting to completing two activities for at least 90 days. For these clinicians, “high” weighted activities are worth 40 points, and “medium” weight activities are worth 20 points.

Clinicians who work in a patient-centered medical home, Medical Home Model or similar specialty practice will automatically receive full credit in the Improvement Activities category.

Clinicians may also earn bonus points for improvement activities that use CEHRT and for reporting to a public health or clinical data registry.

Table 4. Integrated Behavioral and Mental Health Improvement Activities

Improvement Activity

Definition Activity Weight

Depression screening

Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.

Medium

Diabetes screening

Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication.

Medium

EHR Enhancements for BH Data Capture

Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).

Medium

Implementation of co-location of PCP and MH services

Integration facilitation, and promotion of the colocation of mental health services in primary and/or non-primary clinical care settings.

High

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Implementation of integrated PCBH model

Offer integrated behavioral health services to support patients with behavioral health needs, dementia, and poorly controlled chronic conditions that could include one or more of the following: Use evidence-based treatment protocols and treatment to goal where appropriate; Use evidence-based screening and case finding strategies to identify individuals at risk and in need of services; Ensure regular communication and coordinated workflows between eligible clinicians in primary care and behavioral health; Conduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment; Use of a registry or certified health information technology functionality to support active care management and outreach to patients in treatment; and/or Integrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible.

High

MDD prevention and treatment interventions

Major depressive disorder: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including suicide risk assessment (refer to NQF #0104) for mental health patients with co-occurring conditions of behavioral or mental health conditions.

Medium

Tobacco use Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.

Medium

Unhealthy alcohol use

Unhealthy alcohol use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including screening and brief counseling (refer to NQF #2152) for patients with co-occurring conditions of behavioral or mental health conditions.

Medium

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SECTION 7

MIPS Reporting Mechanisms

MIPS eligible clinicians may report as individuals or as part of a clinician group. An individual is defined as a National Provider Identifier (NPI) tied to a single Tax Identification Number (TIN). A group is defined as two or more clinicians, identified by their NPIs, who share a common TIN regardless of the specialty or practice site.

Groups will be assessed as a group across all performance categories, and will receive one payment adjustment based on the group’s performance. Groups will NOT be required to register to have their performance assessed as a group, except for groups submitting data on performance measures via participation in the CMS Web Interface or groups electing to report the CAHPS for MIPS survey for the quality performance category. These groups must register no later than June 30, 2017. For all other data submission methods, groups must work with appropriate third party entities as necessary to ensure the data submitted clearly indicates that the data represent a group submission rather than an individual submission.

CMS Funded Technical AssistanceCMS is investing $100 million in technical assistance over five years to assist clinicians in rural areas, medically underserved areas, and practices with low MIPS final scores or those in transition to APM participation. See the CMS Quality Payment Program website for updates.

Transforming Clinical Practice Initiative Practice Transformation Network (PTNs) will assist 140,000+ clinicians to achieve large-scale health transformations over four years.

SECTION 8Additional Resources

National Council for Behavioral Health ResourcesMACRA Webpage

MACRA Webinar Series

MACRA Fact Sheet

Capitol Connector Blog

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CMS ResourcesQuality Payment Program Service Center

• 1-866-288-8912

• 1-877-715-6222

Quality Innovation Networks (QINs) & Quality Improvement Organizations (QIOs)

Transformation Clinical Practice Initiative (PTNs and SANs)

Self-service Quality Payment Program Online Portal (QPP)

QUESTIONS?Elizabeth Arend, MPH

Quality Improvement AdvisorElizabethA@TheNationalCouncil.org