On September 16, 2019, Policy & Medicine editor Thomas Sullivan presented an interactive working session during the 17th Annual Independent Medical Education and Grants Summit, “Repackage Your CME Programs for MIPS Compliance.” Other presentation participants include Andy Rosenberg, JD, Senior Advisor with the CME Coalition; Terry Glauser, MD, MPH, the Medical Director at Rockpointe; and Amanda Kaczerski, Senior Director for Educational Strategy and Design at the Academy for Continued Healthcare Learning.
The program started out by explaining that the Merit-based Incentive Payment System (MIPS) is part of the Quality Payment Program (QPP), which was created under MACRA. Under the QPP, there are two paths under which a clinician can receive payment: an alternative payment model and a fee for service model. The fee for service model is based on performance and is where MIPS falls.
MIPS providers fall under a variety of categories, with expanded definitions in 2020. MIPS providers include physicians (MDs, DO’s, dentists, optometrists, etc.), physician assistants, nurse practitioners, certified nurse midwives, clinical social workers, and registered dietitians, just to name a few. Exempt clinicians include those who are at or below the Low Volume Threshold (less than $90,000 in Medicare billing or less than 200 patients).
MIPS allows for payment adjustments to be made for providers who either exceed a certain number of MIPS points (upward adjustment) or who fall below a certain number of MIPS points (downward adjustment). For 2019, to avoid a penalty, clinicians must have 30 MIPS points, whereas to be eligible for a bonus, clinicians must have 75 MIPS points. For 2020, those numbers go up to 45 and 80, respectively. In 2019, the maximum bonus incentive is 7% while the maximum penalty is 7%; in 2020, the maximum incentives and penalties go up to 9%.
In 2017, the first year of QPP, there were 1 million participants, 93% of which earned a positive payment. However, as the years go on and the requirements become more stringent, it is likely that fewer participants will earn positive payment.
The MIPS Composite Performance Score is made up of four different factors, each weighing differently: Quality Measures, Resource Use/Cost, Improvement Activities, and Promoting Interoperability. The weight of Quality Measures and Resource Use of Cost fluctuates going from a 45%/15% split in 2019, to a 40%/20% split in 2020, and a 35%/25% split in 2021. Improvement Activities and Promoting Interoperability remain at 15% and 25%, respectively, through all three years. CME has a unique place because it is able to not just teach scientific knowledge, but can also be used to teach clinicians how to use quality measures, promote interoperability, and use less resources.
What Activities Qualify as Improvement Activities?
Ms. Kaczerski then walked participants through what kind of activities qualify as improvement activities and what to consider. Some things to consider when planning a CME for MIPS Improvement Activity:
- it must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;
- it must have specific, measurable aim(s) for improvement; it must include interventions intended to result in improvement;
- it must include data collection and analysis of performance data to assess the impact of the interventions;
- and the CME provider must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information.
For 2020, there is a proposal that an example of an activity that could satisfy the improvement activity is completion of an accredited CME program related to opioid analgesic risk and evaluation strategy (REMS) to address pain control (both acute and chronic pain).
Ms. Kaczerski also pointed to a helpful resource on the ACCME website, CME for MIPS, which can be found here. It includes several resources and step-by-step guides.
How to Gather Data
Terry Glauser, MD, MPH, spoke about a worksheet developed by Rockpointe Corporation to help develop CME improvement activities and ensure that they meet the QPP criteria.
To help gather MIPS data, Dr. Glauser noted that initial MIPS questions are included in the program evaluation and are typically phrased as “how often do you currently…” or “how many patients do you currently do this for…” and are clearly marked as MIPS questions. There is also a statement included that lets the participating clinicians know that they will receive two follow-up surveys on the questions and will need to show improvement in order to claim MIPS credit. To help the doctors show improvement, the answers should be multiple choice and have a range (i.e., 10-20%, 21-30%, or rarely, frequently, always) to show a change over time.
It is important to note that the participating clinicians are responsible for reporting the MIPS activity to CMS. Rockpointe has the data and can back them up, but they do not make the reporting.
Sample Content
In the presentation, two sample slides were provided for content on what to do – one for live activity and one for an enduring activity.
After-Activity Instructions
While there isn’t a one-size-fits all solution, the CME Coalition and Rockpointe Corporation has been at the forefront of helping to develop systems for these activities. Some suggestions for post-activity actions are: give clinicians learners a choice of up to three areas to improve their quality, identify the participants who checked the MIPS box on the evaluation, make sure to have valid emails for those who want to participate in MIPS, send out the survey email 30 and 90 days after the program, send out a certificate of completion to the participant once all three evaluation surveys are complete, and generate a report that goes into PARS.
Future of MIPS
In 2021, CMS plans to add MIPS value pathways, combining quality measures, meaningful use, computer use, interoperability measures into bundles so clinicians can be successful.
The CME Coalition is working to ensure CME is included in MIPS and that history does not repeat itself. Historically, programs get dumped on doctors without CME improvement activities where no one knows what to do.
Questions
Some of the questions from the session are included here, as well as responses from Mr. Sullivan, Mr. Rosenberg, Ms. Kaczerski and Dr. Glausner.
Q: Do you have to use quantitative data?
A: No, you do not have to only use quantitative data. You can also use portfolio data and any other data available to you as a clinician. It doesn’t have to be numbers oriented, it just has to show improvement.
Q: What is the success rate on clinicians completing CME for MIPS?
Typically 50% of clinicians attending say they’re interested at the beginning of the program. Roughly 30% complete the survey 30 days out, and an estimated 10-20% complete the final survey.
Q: Are there success stories during outcomes reporting? How is it done differently when analyzing data from MIPS completers versus general?
A: At this time, MIPS programs are done in series so there hasn’t been a full outcome analysis done, but a series on REMS is being done this year: twelve live meetings plus online interactions.
Q: How much “hand holding” does this take with providers?
A: There hasn’t been anyone who has come back and said they’ve gotten a lot of questions, just occasional emails asking for more detail. However, there is a lot of faculty training to be done because faculty doesn’t know how all of this works yet. Rockpointe has had to do a lot of staff training within the company to get everyone on the same page. For example, when MIPS first started, the company held monthly conference calls to get everyone trained and on board.
Q: For someone who is new to this and interested in CME for MIPS, what format is best to start and test the waters?
A: There isn’t necessarily one format that is better than others, but it has more to do with what the education is about: you are looking to change physician performance in some way. If you’re just doing knowledge-based CME, that is not a candidate for CME for MIPS. However, as long as you can ask participants to quantify what they are doing now and reevaluate their actions 30 and 90 days out from the event, it qualifies for MIPS.
Q: How can you address/mitigate clinician fears about being involved and MIPS for CME creating more work for them?
A: They have to do the CME anyway. It isn’t much more work in addition to the actual CME course. The only additional requirements are to initially evaluate where they are, and re-evaluate in 30 days and 90 days – two additional questions. Often, clinicians object to the “other stuff” they have to do, more burdensome in terms of paperwork. Educate clinicians on how easy it is to get MIPS credit.
Q: Can clinicians get around not doing MIPS and still receive Medicare payments?
A: Yes, but if they opt out and still qualify (see more than 200 patients, bill more than $90k) there is an 18 point swing, they can either lose $9k or gain $9k.
Q: With ACCME rules/regulations, is this a special accreditation providers are getting? Or are they using regular CME to fulfill this criteria?
A: CME for MIPS is regular CME with a focus on how clinicians can improve their practice.