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Understanding Your Merit-based Incentive Payment System Performance Feedback Report

Hess, Cathy Thomas, BSN, RN, CWCN

Advances in Skin & Wound Care: May 2019 - Volume 32 - Issue 5 - p 239–240
doi: 10.1097/01.ASW.0000557617.62922.9d
DEPARTMENTS: PRACTICE POINTS
Free

Cathy Thomas Hess, BSN, RN, CWCN, is Vice President and Chief Clinical Officer for Wound Care, Net Health. Ms Hess presides over Net Health 360 WoundExpert Professional Services, which offers products and solutions to optimize process and workflows. Address correspondence to Ms Hess via email: chess@nethealth.com.

After taking the time to diligently document and report your Merit-based Incentive Payment System (MIPS) measures and activities, it is important to review your Performance Feedback Report1,2 detailing the category scores for your MIPS data submission. The scores provide you with payment adjustment information (excluding voluntary submitters) and details about measures and activities. Clinicians participating in the MIPS or Advanced Alternative Payment Models (APMs) track of the Quality Payment Program may receive feedback on their performance to identify areas of excellence and improvement.

The following information details the MIPS information submitted in 2017 for the 2019 payment adjustment.2 Review the entire fact sheet and user guide for complete details.1,2

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Who Will Have MIPS Performance Feedback?

Individual clinicians (including voluntary submitters), groups, and MIPS APM entities (ie, those with MIPS-eligible clinicians scored under the APM scoring standard) will receive MIPS performance feedback. Clinicians who practice in multiple groups (as identified by a Taxpayer Identification Number [TIN]) will have performance feedback for each group under which they participated in MIPS. Partial qualifying APM participants will only receive MIPS performance feedback if they elected to participate in MIPS. Qualifying APM participants will not receive MIPS performance feedback.

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What Is MIPS Performance Feedback?

At the end of the submission period, the Centers for Medicare & Medicaid Services started providing preliminary performance feedback to share scores in progress. These preliminary scores were subject to change as more data became available, such as:

  • Scoring updates based on a special status (eg, reweighting the Advancing Care Information [now known as Promoting Interoperability; this column will use Advancing Care Information because that is what will appear on clinicians' feedback forms as stated within the Fact Sheet] performance category to 0% for hospital-based MIPS-eligible clinicians)
  • All-Cause Hospital Readmission measure calculations
  • Consumer Assessment of Healthcare Providers & Systems for MIPS Survey results
  • Advancing Care Information hardship exception application status
  • Improvement Study Participation and Results
  • Performance period benchmarks for quality measures that did not have a historic benchmark

Final MIPS performance feedback, available in July 2018, reflects special scoring circumstances and all the MIPS data submitted or calculated for an individual clinician, group, or APM entity. This final feedback includes the 2017 final score, 2019 payment adjustment information (excluding voluntary submitters), and details about measures and activities.

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How Do I Access My MIPS Performance Feedback?

Individual clinicians, groups, Medicare Shared Savings Program Accountable Care Organizations (ACOs), and Next Generation ACOs, as well as their authorized representatives, can access performance feedback by logging into qpp.cms.gov with their HARP (Healthcare Quality Information System Access Roles and Profile)3 credentials (previously known as Enterprise Identity Data Management credentials) that allowed them to submit and view their data during the submission period.

  • Shared Savings Program ACOs will have access to final MIPS performance feedback at the APM entity (ACO primary TIN) level. Groups and solo practitioners participating in a Shared Savings Program ACO (ACO Participant TINs) will also be able to access the APM entity-level feedback by logging into qpp.cms.gov.
  • Next Generation ACOs will have access to MIPS final performance feedback at the APM entity (primary TIN) level only.
  • All other MIPS APM participants will receive their payment adjustment and performance feedback directly from their APM entity, not by logging into qpp.cms.gov.

With the exception of Shared Savings Program and Next Generation ACOs, APM entities with MIPS-eligible clinicians scored under the APM scoring standard will not be able to access their MIPS performance feedback by logging into qpp.cms.gov and therefore will not need to get HARP accounts to access performance feedback.

  • Final MIPS performance feedback will be distributed by the specific APM team to APM entities with at least one MIPS-eligible clinician scored under the APM scoring standard.

If you do not have a HARP account, start the process now to ensure you can access MIPS performance feedback in a timely manner, and if necessary submit a request for targeted review if you believe there are errors in your final score or payment adjustment.

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What Is Included in My Final MIPS Performance Feedback?

Final MIPS performance feedback will include the following information for each individual clinician, group, or APM entity:

  • 2017 final score;
  • 2019 MIPS payment adjustment applied to MIPS-eligible clinicians (note that payment adjustments will not be applied to voluntary submitters);
  • final performance category scores and weights;
  • scoring and performance details for the Quality and Advancing Care Information measures;
  • scores for improvement activities;
  • performance details for cost measures (informational only for 2017 and not applicable to MIPS-eligible clinicians who are scored under the APM scoring standard); and
  • items and services, for example, information about emergency department utilization for attributed beneficiaries (this information has no impact on your MIPS score).
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PERFORMANCE FEEDBACK

The Performance Feedback Overview identifies the score, performance period, highest scored data submission mechanism, and number of measures submitted through that mechanism for each performance category. Each category also includes a section that identifies the lowest-scoring measures that counted toward the final score or other indicators of how performance could have been improved.

In addition to the overview, performance feedback includes details about the measures and activities reported and information about how your score was calculated for each performance category.

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Quality

  • Measure-level scores, including performance and/or bonus points
  • Benchmark information
  • Performance rates
  • Numerator and denominator values
  • Access to measure specifications
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Advancing Care Information

  • Measure-level performance scores
  • Numerator and denominator values
  • Access to measure specifications
  • Indicator of special scoring considerations, such as reweighting to 0% because of an approved hardship exception
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Improvement Activities

  • Weight of each submitted activity
  • Scores for each submitted activity
  • Access to activity specifications
  • Indicator of special scoring considerations, such as full credit in the category for participation in the improvement activity study
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Cost

  • Not applicable to MIPS-eligible clinicians who are scored under the APM scoring standard
  • Measure-level scores (informational only, because this measure does not contribute to the final score in the transition year)
  • Measure-specific details such as the number of eligible cases or episodes and the average cost per episode
  • Access to measure specifications
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Items and Services

This section includes information about Medicare-covered items and services furnished to your patients by other suppliers and providers of services as required by statute. During feedback sessions, clinicians identified the importance of emergency department utilization metrics in informing them about their patients’ frequency and use of the emergency department. Providing meaningful and actionable information to clinicians is the first step in assisting clinicians in managing care efficiently. Because this information was identified as actionable and important to clinicians, final MIPS performance feedback will also include

  • the number of your attributed beneficiaries,
  • the number of your attributed beneficiaries who visited an emergency department in the last calendar year, and
  • the number of emergency department visits by your attributed beneficiaries in the last calendar year.

See the Performance Feedback Fact Sheet2 for further information and frequently asked questions. Now, start to review your hard work!

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REFERENCES

1. Quality Payment Program. 2017 Performance Feedback User Guide. Created August 13, 2018. https://qpp.cms.gov/about/resource-library. Last accessed March 25, 2019.
2. Quality Payment Program. 2017 Performance Feedback Fact Sheet. Created July 13, 2018. https://qpp.cms.gov/about/resource-library. Last accessed March 25, 2019.
3. Centers for Medicare & Medicaid Services. HARP Help: Frequently Asked Questions. https://harp.qualitynet.org/login/help. Last accessed March 25, 2019.
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