MIPS, Ready or Not

Get­ting IT sys­tems ready for new de­mands starts now.

Health Data Management - - INSIDE - By John Mor­ris­sey

Many providers still lack the data they need for the shift to value-based care.

The Merit-based In­cen­tive Pay­ment Sys­tem—the re­im­burse­ment sys­tem the gov­ern­ment will use to move Medi­care pay­ments to a qual­ity- and value-based ap­proach—is in its ini­tial year.

While 2017 is deemed a per­for­mance pe­riod, changes lie ahead, and providers may not re­al­ize the full im­pli­ca­tions of how they will be af­fected. The pro­gram com­bines three fed­eral re­port­ing pro­grams—mea­sur­ing qual­ity, value and the mean­ing­ful use of elec­tronic health records—into one. And it’s the bal­ance of these three com­po­nents that is shift­ing.

MIPS em­pha­sizes qual­ity mea­sure­ments more at the out­set, but the ap­proach will even­tu­ally seek to grade clin­i­cians based on their abil­ity to con­trol costs. The base­line for those cal­cu­la­tions is be­ing es­tab­lished by the Cen­ters for Medi­care and Med­i­caid Ser­vices this year. And ex­perts be­lieve that many providers don’t have all the in­for­ma­tion sys­tems in place—or use them in com­bi­na­tion—to ac­cu­rately pre­pare for the shift.

Health­care ex­perts con­tend that providers need to start scram­bling now to have the data to be able to en­sure they’re able to gather and act on cost data—not just from their own prac­tices, but all costs that as­signed pa­tients in­cur.

“Here’s the chal­lenge: Where does the data come from that pro­vides that kind of knowl­edge, on an al­most real-time, ev-

er-evolv­ing ba­sis?” says Rod Piechowski, se­nior direc­tor for health in­for­ma­tion sys­tems at HIMSS. “With­out base­line data, and some­one hav­ing al­ready done the anal­y­sis on all these dif­fer­ent de­tails, physi­cians aren’t equipped to make those kinds of cost de­ci­sions.”

Change in fo­cus

This year, MIPS gen­er­ally fo­cuses on qual­ity met­rics, a cat­e­gory that ac­counts for 60 per­cent of a score de­rived from four cat­e­gories of physi­cian per­for­mance. By con­trast, cost per­for­mance has no im­pact on re­im­burse­ment. That will change as the pro­gram pro­gresses, with prac­tices be­com­ing im­pacted by the costs as­so­ci­ated with car­ing for as­signed pa­tients.

Prac­tices have had years of ex­pe­ri­ence deal­ing with qual­ity met­rics, nav­i­gat­ing both the Physi­cian Qual­ity Re­port­ing Sys­tem (PQRS) and mean­ing­ful use cri­te­ria of the fed­eral EHR in­cen­tive pay­ment pro­gram. But a sys­tem­atic, an­a­lyt­i­cal ap­proach to cost ac­count­ing and man­age­ment is not nearly as com­mon, and the IT sys­tems to sup­port it is likely a mul­ti­year un­der­tak­ing, ex­perts say.

Physi­cians nav­i­gat­ing this im­mi­nent ba­sis for Medi­care re­im­burse­ment will be li­able not just for their prac­tice-gen­er­ated cost but also Medi­care spend­ing by their pa­tients, both as hos­pi­tal in­pa­tients and in post-acute set­tings.

Even­tu­ally, 30 per­cent of physi­cians’ MIPS score will be based on their cost habits and con­se­quences of spend­ing de­ci­sions. CMS will pro­vide the cal­cu­la­tions, gen­er­at­ing an in­di­vid­u­al­ized re­port that providers will re­ceive at the end of a re­port­ing year from claims data.

To per­form well un­der MIPS, med­i­cal groups and health sys­tems can’t be in a po­si­tion of wait­ing for their CMS re­ports—that comes too late to make im­prove­ments, says Karen Knecht, chief in­no­va­tion of­fi­cer of En­core Health Re­sources. “This will be one of the larger chal­lenges [of MIPS]. CMS will do the cal­cu­la­tions for them, but they’re go­ing to want to an­tic­i­pate what their cal­cu­lated re­source use will be.”

That makes 2017 cru­cially im­por­tant. It’s a year of zero cost ac­count­abil­ity for MIPS, and it’s an op­por­tu­nity to fig­ure out what data to iden­tify and ac­cu­rately cap­ture; what an­a­lyt­i­cal ser­vices will help track costs prac­ticewide, down to the in­di­vid­ual doc­tor; and the process to put this data in front of physi­cians so they make cost-ef­fec­tive de­ci­sions.

That calls for sig­nif­i­cant tech­nol­ogy and op­er­a­tional change on top of the ex­ist­ing in­fras­truc­ture for qual­ity im­prove­ment, says Piechowski.

To achieve those aims or any others, a min­i­mum level of IT in­fras­truc­ture has to first be in place, says Tony Pan­jamapirom, se­nior con­sul­tant for re­search at the Ad­vi­sory Board. The first is a cer­ti­fied EHR act­ing as a data col­lec­tion sys­tem. Next is a per­for­mance mon­i­tor­ing sys­tem with the abil­ity to bring to­gether data from mul­ti­ple in­for­ma­tion sys­tems, not just the EHR.

Data ag­gre­ga­tion is re­quired to sup­port MIPS cost met­rics and pro­duce in­ter­nal mea­sures to act upon, along with at least a near-real-time per­for­mance re­port­ing ca­pa­bil­ity to feed re­sults back con­tin­u­ally to physi­cians so they see how they fare against their col­leagues and na­tional bench­marks, he says.

A cost man­age­ment IT plan in­evitably cir­cles back to the im­por­tance of giv­ing physi­cians data in a form they can grasp and is easy to work with. Physi­cian buy-in can take years, says Jen­nifer Glen­den­ing, direc­tor of qual­ity and clin­i­cal ef­fec­tive­ness for Cooper Univer­sity Health Care, Cam­den, N.J. “I think the in­pa­tient physi­cians have a bet­ter un­der­stand­ing, but the out­pa­tient world is re­ally go­ing to be im­pacted heav­ily by the MIPS pay­ment sys­tem. So we’re al­ways look­ing for new ideas.”

Cost con­cen­tra­tion

The CMS fo­cus on cost assess­ment car­ries over into MIPS from an ex­ist­ing pro­gram that pro­vides a pay­ment dif­fer­en­tial un­der the Medi­care physi­cian fee sched­ule based on cost per­for­mance against a na­tional bench­mark. This Value-Based Pay­ment Mod­i­fier pro­gram—which pro­vides for dif­fer­en­tial pay­ment to a physi­cian or group of physi­cians un­der the Medi­care Physi­cian Fee Sched­ule based on the qual­ity of care fur­nished com­pared with the cost of care dur­ing a per­for­mance pe­riod—will not be much dif­fer­ent at all when it be­comes part of MIPS in 2018, says Pan­jamapirom.

Cost mea­sures will be grouped into three dif­fer­ent types: to­tal cost per at­trib­uted Medi­care ben­e­fi­ciary; Medi­care Part A and B spend­ing per hos­pi­tal ad­mis­sion; and costs rel­e­vant to cer­tain pro­ce­dures in episodes of care, a way to ap­pro­pri­ately mea­sure the per­for­mance of spe­cial­ists.

The first type en­com­passes all costs in­curred for a ben­e­fi­ciary, in any set­ting. The spend­ing per hos­pi­tal ad­mis­sion cov­ers all costs from three days be­fore the in­pa­tient stay un­til 30 days post­dis­charge.

The time span and par­tic­i­pat­ing physi­cians in a pa­tient care episode—10 such types of episodes in the first year—are trig­gered by codes in pa­tient med­i­cal claims, and the provider re­spon­si­ble for a plu­ral­ity of the re­sult­ing com­piled costs be­comes at­trib­uted to that episode, Pan­jamapirom says.

“Be­cause it’s ret­ro­spec­tive, you have to make sure you’re on top of the cost of the ser­vices you pro­vide to the pa­tient,” he em­pha­sizes, and that in­cludes us­ing cost feed­back to an­tic­i­pate the ar­eas that need to be brought un­der con­trol. Physi­cian groups can start by tak­ing ad­van­tage of Qual­ity and Re­source Use Re­ports, pro­duced twice yearly by CMS. The 2017 QRUR is slated for dis­clo­sure in the fall, ac­cord­ing to CMS.

This cat­e­gory of MIPS could be cru­cial to fi­nan­cial suc­cess. “A lot of providers have done PQRS so far, they have done mean­ing­ful use,” Pan­jamapirom says. “It’s likely that the per­for­mance dif­feren-

tia­tor could be com­ing from the cost com­po­nent of MIPS.”

An­a­lyz­ing cost sources

The first steps in get­ting the data to drive bet­ter re­source use in­clude a cost-ori­ented grasp of the broad is­sues around in­pa­tient length of stay, read­mis­sions, mor­tal­ity rate and other fa­mil­iar per­for­mance mea­sures, drilling down to the per­for­mance of in­di­vid­ual physi­cians in a prac­tice, ex­perts say.

A good sense of how a provider or­ga­ni­za­tion uses re­sources can be at­tained through Health­care Com­mon Pro­ce­dure Cod­ing, which CMS and pri­vate in­sur­ers use in claims pro­cess­ing. A ser­vice of Premier, the na­tional health­care al­liance, HCPC uses codes col­lected from hos­pi­tals to an­a­lyze physi­cian re­source uti­liza­tion, says Lori Har­ring­ton, vice pres­i­dent of qual­ity and reg­u­la­tory so­lu­tions at Premier. It iden­ti­fies the high-dol­lar, low-qual­ity, high-vol­ume overuti­liza­tion of sup­plies and care sites, and reg­u­lar re­ports is­sued to hos­pi­tals en­able com­par­i­son of costs for every physi­cian in a fa­cil­ity, she says.

For ex­am­ple, a com­bi­na­tion of EHR data min­ing and con­tracted an­a­lyt­i­cal ser­vices forms the foun­da­tion of a cost man­age­ment func­tion at Cooper Univer­sity Health Sys­tem that al­ready has demon­strated it can save mil­lions of dol­lars when used as a guide for process change and as a con­tin­u­ous source of cost con­text for physi­cians in their daily work.

Cooper makes use of sev­eral Premier an­a­lyt­i­cal ser­vices to drive cost con­trol and qual­ity im­prove­ment in its in­pa­tient, am­bu­la­tory and post-acute ac­tiv­i­ties, says Glen­den­ing. The am­bu­la­tory per­for­mance im­prove­ment push uses the Premier tool in con­cert with the health sys­tem’s Epic EHR plat­form, draw­ing data from both sources to be an­a­lyzed by a data sci­en­tist and sev­eral data an­a­lysts on staff.

Places to im­prove stand out more when com­pared with how other or­ga­ni­za­tions are do­ing. Quar­terly re­ports from Premier com­pare Cooper with peer groups on is­sues such as pa­tient safety, length of stay, read­mis­sions, mor­tal­ity and re­source uti­liza­tion. Last year the health sys­tem iden­ti­fied res­pi­ra­tory therapy and blood uti­liza­tion as out of kil­ter on re­source use, Glen­den­ing says.

Closer in­spec­tion in its own in­for­ma­tion sys­tems of the flagged ac­tiv­i­ties showed spe­cific prob­lems in plasma and red blood cell man­age­ment, ex­penses in one small area that, along with other in­cre­men­tal ex­penses, add up to a higher cost of treat­ing Medi­care ben­e­fi­cia­ries, and that’s what the cost cat­e­gory of MIPS will be track­ing.

Medi­care spend­ing per ben­e­fi­ciary is chal­leng­ing, partly be­cause “a lot of these pa­tients are read­mit­ted mul­ti­ple times, there’s a lot [of con­cern] over us­age of re­sources when pa­tients are here in the hos­pi­tal, and we know that we need to get a lit­tle tighter with how we’re us­ing the right re­sources for the right pa­tient,” Glen­den­ing says.

Find­ing ac­cu­rate data

The ac­cu­racy and com­plete­ness of cost-re­lated data will fig­ure highly into any suc­cess in manag­ing how well re­sources are used. Pre­cise doc­u­men­ta­tion helps or­ga­ni­za­tions un­cover a prob­lem sooner and ad­dress it be­fore CMS de­ter­mines the MIPS cost score.

With ac­cu­rate data to an­a­lyze, providers can start iden­ti­fy­ing high-dol­lar, high-vol­ume items and de­ter­mine whether, for ex­am­ple, the ad­min­is­tra­tion is ne­go­ti­at­ing the best price for sup­plies. Only af­ter cod­ing and pric­ing are op­ti­mized can is­sues of re­source use be taken on, Har­ring­ton em­pha­sizes.

At Cooper, all goods and ser­vices are billed and charged through an up­grade in the Epic plat­form for the en­tire en­ter­prise, in­stead of us­ing a sep­a­rate charge cen­ter. So all data sent to Premier comes through that one Epic source, says Glen­den­ing. Physi­cians un­der­stand bet­ter the im­pact and met­rics of cost gen­er­ated through Epic data and an­a­lyzed by the out­side al­liance.

Physi­cians prac­tic­ing in the Cooper sys­tem are learn­ing that ev­ery­thing they do af­fects cost, and “there’s a more con­scious de­ci­sion for every order that they place, and every ad­mis­sion ver­sus ob­ser­va­tion sta­tus, for ex­am­ple,” she says.

The on­set of MIPS de­mands for ef­fi­cient physi­cian prac­tices will put even more pres­sure on their daily rou­tine, mak­ing the pre­sen­ta­tion of data for cost de­ci­sions as im­por­tant as the in­for­ma­tion it­self. “Ba­si­cally [CMS is] ask­ing the in­di­vid­ual physi­cian to un­der­stand the un­der­ly­ing cost struc­ture of the en­tire op­er­a­tion, its work­flow and sup­ply chain, while they are pro­vid­ing care,” says Piechowski of HIMSS.

Holis­tic ap­proach

Once ar­eas of con­cern re­gard­ing cost come into fo­cus, a savvy choice of ini­tia­tives in other cat­e­gories of MIPS can rack up points in those ar­eas while hav­ing a pos­i­tive ef­fect on clin­i­cal cost and re­source use, says Knecht of En­core. For ex­am­ple, op­por­tu­ni­ties abound in the cat­e­gory of prac­tice im­prove­ment ac­tiv­i­ties that can get at re­source use prob­lems at the same time.

The MIPS pro­gram is de­signed with a holis­tic ap­proach to im­prov­ing qual­ity and low­er­ing cost, though the mind-set of­ten is to treat each cat­e­gory sep­a­rately, Har­ring­ton says.

For ex­am­ple, a group of physi­cian prac­tices might be poor at co­or­di­nat­ing care ac­tiv­i­ties with hos­pi­tals and other points on a con­tin­uum of care, driv­ing up test vol­ume and lead­ing to un­nec­es­sary, costly du­pli­ca­tion. One way to achieve im­prove­ments is to es­tab­lish ef­fec­tive care co­or­di­na­tion and re­fer­ral man­age­ment that pro­motes bet­ter pa­tient track­ing across care set­tings.

In ad­di­tion, one of the met­rics on the qual­ity pick list deals with clos­ing the re­fer­ral loop with spe­cial­ists, mea­sur­ing the per­cent­age of re­ferred pa­tients for whom the re­fer­ring doc­tor re­ceives a re­port from the pa­tient’s treat­ing physi­cian. And for good mea­sure, one scor­ing pos­si­bil­ity un­der ad­vanc­ing care in­for­ma­tion is to per­form clin­i­cal in­for­ma­tion rec­on­cil­i­a­tion dur­ing a tran­si­tion of care or re­fer­ral sit­u­a­tion.

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