8 Essentials to Perform Well Under MIPS

8 Essentials to Perform Well Under MIPS

The Merit-based Incentive Payment System (MIPS) will have huge financial and reputational impact on clinicians and hospitals. As MIPS reporting approaches, you may be asking yourself, how do we better prepare, and how do we better perform? Further, as the incentive payment percentages and competition increase each subsequent year, these questions will be continuously re-evaluated. To help you answer these two questions, we’ve identified how clinicians, practices, and organizations can better prepare and perform for MIPS.

1.      Create a Sense of Urgency

Some providers are prepared for MIPS. Some are not. For those who are not prepared, the first rule of any change management process is to create a sense of urgency. For key stakeholders (administration, providers, clinical teams, IT, etc.) to adopt a radical change like MIPS, we must install the impression that staying where you are is not an option. Whether it is the impact on revenue, provider reputation, improving the health in the community, or becoming a top performer as an organization, it is critical to building a strong narrative and alignment around this initiative. Striving for proactive, continuous improvement by creating a sense of urgency and utilizing change management is the first step to prepare for MIPS.

2.      Form a Steering Committee

Once urgency and motivation for change have been installed, the next step is to form a MIPS steering committee. A steering committee will strive to provide guidance and support and think through any potential roadblocks. The MIPS steering committee should be charged to create a strategy, high-level plan, and timeline. A charter with a problem statement, goals, scope, timeline and key resources would provide a better understanding of the initiative. I encourage you to have a multidisciplinary steering committee consisting of providers, frontline staff, administrators, IT, and finance.

3.      Identify a Technology Partner

There are 271 different quality measures that can be tracked and reported under the Quality Payment Program (QPP). Collecting, tracking, and reporting these MIPS measures will require IT capabilities beyond the existing EMR, in most cases. Most EMRs provide basic quality measures, but gaps exist in tackling other data sources, provider specific scorecards, intuitive dashboards to monitor progress, predictive analytics, and specific reports exposing gaps in documentation and clinical care.

It is very important to understand the current functionalities of your EMR, identify gaps that might exist, and evaluate where there is a need for further technology. If a technology solution is needed to close gaps, selecting the right partner is critical, as EMR integration is expensive and timely.

4.      Understand the Data Sources and Data Submission Methods

For the 2017 performance period, there are 3 major categories – Quality, Advancing Care Information, and Improvement Activities. With 2017 being a transition year for the QPP, your options are: submit some data; report for a 90-day period; or full participation. Not participating will result in a negative 4% payment adjustment.

There are 271 Quality measures, 92 Improvement activities across 8 sub-categories, and 15 Advancing Care Information objectives and measures. It is important for your team to understand these various options.

5.      Establish Baseline, Benchmark, and Identify Gaps to Focus on

Once there is a good understanding of MIPS measures and activities, the next step is to measure available data and establish baseline performance. Throughout this process, it is vital to comb your data for accuracy, validity, and reliability to identify strengths and gaps. Be on the lookout for documentation errors.

After baseline performance has been established, benchmark your quality measure performance with the recently released benchmarks by CMS. Under these benchmarks, a clinician can receive anywhere from 3 to 10 points per measure. By comparing current/baseline performance to CMS benchmarks, it will become apparent which metrics have the most opportunity for documentation and clinician improvement. Using this information, your team can begin working on quality improvement.

6.      Invest in Performance Improvement / Change Management

To be successful under MIPS, effectively adopting change is essential. Consider using a data-driven, team based, and patient-centered continuous improvement program. This is an often-overlooked aspect of the change strategy. Outcomes do not magically improve by just sharing the data with care teams and providers. Improvement requires multi-disciplinary teams using structured performance improvement methodology to effectively make change happen.

Outcomes do not magically improve by just sharing the data with care teams and providers

7.      Improvement Projects: Select Few, Start Small, and Celebrate Early Wins

Based on the identified gaps in Quality, Advancing Care Information, and Improvement Activities, only a few improvement projects will need to be selected. Use a structured performance improvement/project management methodology and secure early wins while working on these projects. The importance of celebrating early wins cannot be understated. Efforts and wins must be heavily publicized and promoted to help further change behaviors and improve MIPS outcomes.

8.      Sustain the Results and Repeat the Cycle

There is no “magic bullet” to ensure that the results are going to be sustained after the early wins. Sustaining these efforts require constant monitoring of outcomes, disciplined routines, and constant vigilance, even after the projects have been closed out. Data must continually be reviewed and processes regularly reevaluated to identify what does and does not work.

Repeat the cycle for continuous, sustainable improvement.

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