The Centers for Medicare & Medicaid Services’ Quality Payment Program rewards value and outcomes through the Merit-based Incentive Payment System (MIPS). This is the fourth year of the program, which measures eligible clinicians’ performance through data reported in four areas to arrive at a final score based on a 100-point scale. The four MIPS categories are:

• Quality (45% of score)
• Promoting Interoperability (25% of score) — formerly Advancing Care Information and previously the Meaningful Use part of electronic health records (EHR)
• Improvement Activities (15% of score)
• Cost (15% of score)

MIPS’ stated goal is to tie payments to quality and cost-efficient care, drive improvement in care processes and health outcomes, increase the use of health-care information and reduce the cost of care.

Eye-care practices are adapting to changes over time and becoming increasingly successful at navigating the program, avoiding penalties and receiving bonuses. MIPS is constantly changing, however, so below is a review of the program. (For a list of online MIPS-related resources, see MIPS Resources.)

RECENT CHANGES

First, a review of some of the key changes for 2020. The performance threshold to avoid a penalty increased from 30 to 45 points, and the exceptional performance bonus threshold jumped from 75 to 85 points. Small practices — those with 15 or fewer eligible clinicians —remain eligible for points applied automatically to the Quality score if the practice submits at least one Quality measure.

The penalty for underperformance has increased from 7% to 9% of the final score, though the full penalty will only apply to the lowest quartile of failures; a lower penalty will be given to practices that fall short of a passing score but do not end up in the lowest quartile.

The Cost performance category remains weighted at 15%, but optometrists and ophthalmologists are excluded from the Total Per Capita Cost measure. Ophthalmologists who perform cataract surgery, however, remain subject to the provisions in the Episode of Cost for Routine Cataract with IOL.

For the Quality category, the data completeness threshold for each quality measure increased from 60% to 70%. Quality Measures 192 (Cataracts: Complications Within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures), 388 (Cataract Surgery With Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) and 474 (Zoster [Shingles] Vaccination) were removed, and several measure specifications were changed.

IRIS REGISTRY AND EHR

Ophthalmology practices that implement certified electronic health record technology (CEHRT) can report MIPS data through the AAO Intelligent Research in Sight (IRIS) registry. The ophthalmology-specific resource is a free benefit for AAO members that functions to streamline MIPS reporting, helping physicians succeed with the program. (Important to note: Starting in 2021, MIPS reporting will be performed through Verana Health instead of IRIS.)

Being proactive is a key to MIPS success. “Plan ahead,” says John A. Hovanesian, MD, who is in private practice at Harvard Eye Associates in Laguna Hills, Calif. “It is very difficult to hurriedly collect data. For us and for many practices, the easiest way to go about this is through the IRIS Registry, which is compatible with most EHR systems. And when your EHR is linked for direct data extraction with the IRIS Registry, you automatically get data collection on most of these parameters for MIPS. It greatly simplifies the process for your practice.”

In addition, Dr. Hovanesian also uses a system called MDbackline, which helps meet the patient engagement requirements of MIPS by automatically sending information on smoking cessation (a requirement) and other health matters more relevant to ophthalmologists, he says. MDbackline is a secure, web-based service that automates physicians’ conversations with patients.

The AAO also helps by working to ascertain areas of MIPS that are troublesome for physicians and where more education is needed. One measure in which eye-care providers fall short is under the Promoting Interoperability category, according to Jessica Peterson, MD, MPH, and AAO manager of quality and HIT policy.

“Ophthalmologists are not doing very well on a measure that requires providers to provide patients access to their health information; in other words, uploading information to the patient portal,” says Dr. Peterson. “We see really low performance on this measure, which is actually quite easy. Providers need to ensure that, through the EHR system, information is uploaded to the patient portal within 4 business days of any encounter and any new info (like labs) becoming available to the physician.”

Capturing this information should be a seamless part of the EHR workflow, she says. If a provider sees low numbers on this measure, the EHR vendor should be able to help iron that out.

HEALTH INFORMATION EXCHANGE MEASURES

Another part of Promoting Interoperability that the AAO has seen contribute to poor MIPS performance is the health information exchange measures. “This is the requirement to send patients’ health information electronically through the EHR to the referring provider or vice versa,” Dr. Peterson says. “Those are very difficult measures. We and other medical societies fought very hard against making them count more because of the variability in EHR workflows. Sometimes this function can be unclear; however, this is another circumstance where providers can talk to their vendor about simplifying the feature.”

Practices must ensure they have the Direct electronic contact for their referring physicians — and their own practice locations. These Direct addresses are a secure way of exchanging health information, and while they look similar to a traditional e-mail address, they are not the same.

“Contact EHR vendors to get these electronic addresses. Keeping the information updated in CMS’ National Plan and Provider Enumeration System, which was developed to assign unique identifiers to providers, is important in terms of maintaining this national database to facilitate provider electronic exchange,” Dr. Peterson says. “The number one complaint I hear at my annual meeting sessions on Promoting Interoperability is, ‘We’ve tried everything. We’ve tried working with our EHR, but we can’t find the Direct addresses.’ So, updating the National Plan and Provider Enumeration System helps the entire profession.”

Success on many of the MIPS measures, including Promoting Interoperability and Quality, comes down to leveraging the practice’s EHR system to its fullest capabilities by working with and lobbying the practice’s EHR vendor. IRIS can also help with other MIPS measures.

EHR MAKES REPORTING EASIER

When choosing the six Quality MIPS measures that best fit their practice or the appropriate Improvement Activities, practitioners must be sure they have documentation. “We have a list in our roadmap resources that offers recommendations on which Improvement Activities are easiest, whether the practice has an EHR or not, that tend to fit best into workflows,” Dr. Peterson says. “Whichever one works best for the practice, make sure to save the suggested documentation in those specifications for at least 6 years.”

For small practices not using an EHR, MIPS reporting is much harder and will continue to get more difficult. “That is intentional, as CMS wants everybody to be on an EHR,” she says. “It’s a lot more burdensome to report manually without access to automatic data extraction for quality measures. Even so, it [MIPS] is doable as long as they apply for a hardship for their Promoting Interoperability categories.”

If the Promoting Interoperability hardship is granted, the Quality category gets an increase in weighting of 25% over what it would have been otherwise.

The bottom line: The consequences of not participating in MIPS are significant. “A 9% cut in the top line for Medicare could potentially equal as much as a 30% cut of the bottom line. So, if practices aren’t using an EHR system, it is time to recognize how costly that is,” says Dr. Hovanesian.

Practices that do not currently have an EHR should perform a cost-benefit analysis for getting a system. “If implementing an EHR system is not an option, they really need to look into their quality measures ahead of time and have a plan in place for manual reporting,” Dr. Peterson says. “The IRIS Registry has quality measures that can be reported manually or electronically that are only available through IRIS Registry — these are QCDR measures or Qualified Clinical Data Registry Measures.”

The IRIS Registry is a great resource for practices to be able to look at their performance and see where they have done well and where they have not.

“The Academy is always here for its members. We understand that this is a difficult time and we really have been stepping it up,” Dr. Peterson says. “We’re always trying to provide more resources. So, if there’s something that eye-care providers need, let us know.”

QUALITY MEASURES

Quality can contribute the most to final MIPS scores, as its default weight is 45% or 45 points, although this can be increased. Some of AAO’s tips on maximizing the Quality score (viewable at www.aao.org/eyenet/mips-manual-2020 ) include:

• Report at least one outcome measure.
• If no outcome measure is available, the practice must report another high-priority measure, such as appropriate use, care coordination, efficiency, patient experience, patient safety and opioid-related measures.
• Report at least six Quality measures, including one from the list above. The Quality score is then based on achievement points for up to six Quality measures plus high-priority and CEHRT bonus points and the Quality Improvement percent score. Explore AAO’s resources for Quality measures that can be reported via IRIS, and visit www.qpp.cms.gov .

AAO recommends practices report on more than six Quality measures to give them a buffer. CMS will determine which of the six measures will provide the best achievement scores, so it makes sense to hedge one’s bets.

To meet the Quality data’s submission thresholds, CMS requires a case minimum of 20 patients and a data completeness of 70% of denominator-eligible patients. Denominator-eligible patients are determined by the reporting measure. CMS also warns against cherry picking when reporting on less than 100% of patients.

When it comes to arriving at a final score, the practice’s performance is compared against benchmarks determined by historical data. For example, for Quality measures, CMS used 2018 performance data to come up with 2020 benchmarks.

The benchmarks can vary, however, based on the method of reporting being used (ie, claims-based, manual data entry or via EHR using IRIS or some other registry). Ultimately, the score — which can vary from 3 to 10 points, depending on the measure graded and any bonus points — comes down to how the provider or practice performs compared to the measure’s historical benchmark (which compares all providers who reported such a measure).

NAVIGATING COVID’S IMPACT ON MIPS REPORTING

Due to the impact of COVID-19, many practices shut down for a portion of the year and had to lay off staff. “The regulatory program can be burdensome, so it’s really incumbent on practices to look at their personnel situation and evaluate how to move forward with MIPS reporting,” Dr. Peterson explains. “Identify what is realistically attainable for the practice and be as honest as possible, then try to choose goals that are in alignment. The Academy’s MIPS hub has a useful table that details each Quality measure to help practices choose the best measures for their setting.”

Certainly, the AAO wants eye-care providers to get perfect MIPS scores. “We are so proud of the performance rate of ophthalmologists,” Dr. Peterson says. “But in this current environment, if participating in the program takes away from the care of patients, or distracts from the ability to keep practices open, then it’s time to gather documentation and apply for a hardship from MIPS.”

There are two different hardship exceptions for MIPS. One option is specifically for the Promoting Interoperability measure, and the other applies to potentially all of MIPS categories, resulting in a practice not being penalized in 2022. (To apply for a hardship, go to www.qpp.cms.gov/mips/exception-applications .)

Providers need to plan for the burden that this pandemic will continue to have on their practices, she adds. “Consider what the practice’s new COVID reality is, and try to troubleshoot and find ways to make sure that you can still succeed in MIPS.”

CONCLUSION

Finally, physicians should make their voices heard.

“After a rule is published in the Federal Register, there is a 60-day public comment period,” says Dr. Peterson. “CMS does consider how many unique comments they get, so every voice matters. It doesn’t mean the proposal will change, but feedback makes a difference. Even if a proposal is not removed, it may be modified.” OM