Operationalizing MACRA QPP MIPS Through the Medical Home

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1/16/2017

Pamela Ballou-Nelson, RN, MSPH, PhD, CMPE

The intent of MACRA’s Quality Payment Program (QPP) is to coordinate patient-centered care across the continuum in a safe, quality manner with good outcomes and controlled costs. The program offers several options to begin or perfect steps leading to this effort to high quality, efficient care supported by technology.

Practices can participate in an Advanced Alternative Payment model (AAPM). Advanced APMs are a subset of APMs, and allow practices to earn more for taking on some risk related to their patients' outcomes. You may earn a 5% incentive payment through an Advanced APM (See the CMS QPP website for the 2017 listing of APM).

The Merit-based Incentive Payment System (MIPS) is another option for participation in Macra QPP. MIPS calculates four domains, three of which are reported on in 2017. Cost will be calculated by CMS, but will not count as part of the composite score in 2017. The three reported domains are:

Quality score is 60% of total composite score for 2017
Improvement activities (IA) are 15% of total composite score for 2017
Advancing care information (AI) is 25% of composite score for 2017

MIPS APM eligible clinicians or groups are clinicians in an APM such as Medicare Shared Savings track 1. These groups hold their participants accountable for the cost and quality of care provided to Medicare beneficiaries. These clinician or groups identify as a “MIPS APM,” and participants in MIPS APMs receive special MIPS scoring under the “APM scoring standard".

If a practice is already a recognized or certified medical home, comparable specialty practice or APM designated as a Medical Home Model, they will automatically earn full credit for the improvement activities category of MIPS.

Achieving medical home recognition or certification will place your practice in an excellent position to achieve all other categories for MIPS reporting, for example:

MIPS Category Advancing Care information (ACI) measures correlate with NCQA 2014 PCMH standards which are:

Electronic prescribing
Patient electronic access
Health information exchange
Care coordination through patient engagement
Participation in public health immunization and clinical data registries
Protection of patient health information

*Quality measures for MIPPS QPP are captured in 2014 standards 6A and 6C*

Measures Clinical Quality Performance
Measures Resource Use and Care Coordination
Measures Patient/Family Experience
Implements Continuous Quality Improvement
Demonstrates Continuous Quality Improvement
Reports Performance
Uses Certified EHR Technology

Cost reporting, while not calculated for 2017 MIPS reporting, is part of the practice analysis with Cost standard 6B 1&2 in NCQA PCMH standards*

Select at least two measures related to care coordination
Select at least two measures affecting your health care costs

As we move to value-based models of care and value based contracting, developing a medical home program will give practices the tools necessary to operationalize MIPS or other quality programs required for success.

For more information on the MGMA Consulting and its services, visit our website.

*NCQA will come out with updated PCMH standards in March 2017 and will remain closely aligned to MIPS QPP.

Written By

Pamela Ballou-Nelson, RN, MSPH, PhD, CMPE

Pamela Ballou-Nelson, RN, MSPH, PhD, has more than 30 years of experience in healthcare management, focusing on practice process transformation, patient-centered medical homes (PCMH), workflow analysis, quality measures, care management, population health and patient activation across the continuum of care. Nelson has worked with both provider and payer organizations to help them work toward alternative care and payment models. As clinical quality director for Adventist Health Network in Chicago, Nelson was responsible for leading physicians and hospital directors in their clinical integration process. Nelson has also worked with numerous commercial payers on quality outcomes and effectiveness measures, including compliance with Medicaid care management programs, along with Medicaid insurance contracts and high-risk and dual-eligible patient programs. She has also trained, advised and mentored more than 80 practices in various levels of readiness, preparing them for value-based payment reform, process improvement, improved quality outcomes and increased efficiency through PCMH recognition with 2011 and 2014 standards. She has a BSN from the University of Utah, an MA from Wheaton College, and an MS and PhD in Public Health from Walden University. In addition, she is an NCQA 2014 PCMH certified content expert and frequently speaks on PCMH transformation for accountable care organizations and population health initiatives.