Assessment of Merit-based Incentive Payment System Improvement Activities

Pressure to improve quality of patient care and control costs is desired over the traditional volume driven fee-for-service reimbursement health care models (Squitieri, Bozic, & Pusic, 2017). Laws have been enacted to reward high performance Medicare clinicians and decrease payments to clinicians who fail to meet performance benchmarks (CMS, 2019 QPP).Merit-based Incentive Payment System (MIPS) is one of two ways providers receivereimbursement from the Medicare Quality Payment Program (QPP) intended to link payments to quality and cost-efficient care, improve processes and outcomes, increase use of healthcare information and reduce cost of care (CMS, 2019 MIPS). Physician reimbursement is determined by a score related to performance categories that include Quality, Promoting Interoperability (PI), Improvement Activities, and Cost (2019). Figure 1 provides an example of how provider groups would receive a Performance Category Score for their overall MIPS payment adjustment. This capstone will focus on the Improvement Activities category that includes use of Patient Reported Outcomes (PROs), Patient Portal, and Patient's Experience of Care Surveys. The Quality Department at the Healthcare System is responsible for tracking Improvement Activities within MIPS. They also serve as a reference for any department that has questions about MIPS and what they can do to improve their Improvement Activity score. Given the need to meet MIPS requirements, this project has the following objectives: a) to assess the usage of PROs, Patient Portal, and Patient's Experience of Care Surveys across multiple specialty groups to determine what performance activities need to be improved to meet goals for the Quality Payment Program, and b) recommend strategies to ensure specialty groups address their unique deficiencies regarding Improvement Activity scores and what they can do to meet their quality goals.

MIPS Improvement Activities 1 Michael Zusi, BSN, RN Assessment of Merit-based Incentive Payment System Improvement Activities University of Utah April 25, 2020 In partial fulfillment of a Master of Science degree College of Nursing Major: Nursing Specialty: Nursing Informatics MIPS Improvement Activities 2 Introduction Pressure to improve quality of patient care and control costs is desired over the traditional volume driven fee-for-service reimbursement health care models (Squitieri, Bozic, & Pusic, 2017). Laws have been enacted to reward high performance Medicare clinicians and decrease payments to clinicians who fail to meet performance benchmarks (CMS, 2019 QPP). Merit-based Incentive Payment System (MIPS) is one of two ways providers receive reimbursement from the Medicare Quality Payment Program (QPP) intended to link payments to quality and cost-efficient care, improve processes and outcomes, increase use of healthcare information and reduce cost of care (CMS, 2019 MIPS). Physician reimbursement is determined by a score related to performance categories that include Quality, Promoting Interoperability (PI), Improvement Activities, and Cost (2019). Figure 1 provides an example of how provider groups would receive a Performance Category Score for their overall MIPS payment adjustment. This capstone will focus on the Improvement Activities category that includes use of Patient Reported Outcomes (PROs), Patient Portal, and Patient's Experience of Care Surveys. Figure 1 Example MIPS Performance Category Score MIPS Improvement Activities 3 The Quality Department at the Healthcare System is responsible for tracking Improvement Activities within MIPS. They also serve as a reference for any department that has questions about MIPS and what they can do to improve their Improvement Activity score. Given the need to meet MIPS requirements, this project has the following objectives: a) to assess the usage of PROs, Patient Portal, and Patient's Experience of Care Surveys across multiple specialty groups to determine what performance activities need to be improved to meet goals for the Quality Payment Program, and b) recommend strategies to ensure specialty groups address their unique deficiencies regarding Improvement Activity scores and what they can do to meet their quality goals. Methods Setting and Context This project was performed in collaboration with the Healthcare System's Quality Department at the Business Services Building to address some of the challenges associated with MIPS Improvement Activities. The Healthcare System has 2,127 providers registered across eight different provider groups. Attending meetings with the Quality Department to discuss Improvement Activities and strategies to improve provider groups Improvement Activity scores took take place throughout the semester. The goal is to work with the Quality Department to evaluate all groups and recognize what groups are using PROs, Patient Portal, and Surveys and meeting the 50% completion objectives and determine what improvements each group requires. MIPS Improvement Activities 4 MIPS Improvement Activities PROs At the Healthcare System, physicians are encouraged to use Patient Reported Outcomes (PROs) to meet required MIPS Improvement Activities. PROs instruments are starting to play a major part in the value-based payment reform. In fact, the Healthcare System's provider groups must prove that at least 50% of their physicians are having their patients complete PROs to acquire a suitable score for reimbursement. PROs can play a unique role of adding patient perspective alongside clinical and organizational indicators for evaluating the effects of new products, selecting treatments, evaluating quality of care, and monitoring the health of the population (Black, et al., 2015). Evidence shows that information from PROs lead to better communication and decision making between doctors and patients and improves patient satisfaction (Nelson et al., 2015). With increasing data suggesting PROs improve patient outcomes, they are still not utilized as often as they should be. According to a recent Health Catalyst survey, only 20% of hospitals regularly used PROs to gauge the quality of their patients care (Bresnick, 2016). Neil Wagle MD, MBA (2017) advises that PROs are the missing link in defining a good outcome. However, PROs are slow to be adopted due to several common challenges such as technology, operational, clinical, and organizational barriers. Technological issues can be a barrier given the need for EHR integration and access to WIFI, and transitions from paper to electronic surveys. There is a need to overcome operational barriers, such as convincing busy participants to partake in tasks that are not required and overcoming the wariness of questionnaires (Foster et al., 2018). Clinician barriers include the lack of capacity to use PROs, as well as perceiving their practice MIPS Improvement Activities 5 will be judged on changes in PRO scores. Organizational deficits include lack of resources to utilize PROs, such as deficiency of administrative support or incorporation of PROs into existing workflows within EHRs. Patient Portal mEVAL is a portal system designed by the Healthcare System to allow patients to document information about PROs instruments that can be used by providers (mEVAL, 2020). Being a separate portal from the EHR charting system used by the Healthcare System is a major disadvantage of mEVAL. Thus, the Quality Department has pushed to transition all PROs Instruments to the Patient Portal, which will instantly transmit information to the EHR for providers to review. Providers using the Patient Portal have access to an enhanced patient portal that provides up-to-date information related to relevant chronic disease, health or blood pressure control, and includes interactive features allowing patients to enter health information and enable bidirectional communication about medication changes and adherence (CMS, 2020). The Patient Portal has been shown to improve patient communication with nurses, physicians, and others in the care team. In addition to PROs seamless data access in the Patient Portal, patients reported increased benefits of reviewing laboratory results, seeing their schedule, and information about who was caring for them and why they were in the hospital (Winstanley, et al., 2017). Patient Experience of Care Surveys Patient Experience of Care Surveys include measuring the patient experience of care through surveys, advisory councils and/or other mechanisms. Surveys are used as predictors for improving overall patient satisfaction and quality Improvment plans that provide the MIPS Improvement Activities 6 opportunity for organizations to better understand patient view and improve quality of care (Al-Abri & Al-Balushi, 2014). Improvement Activity Scoring To score the Improvement Activity, the Centers for Medicare & Medicaid Services have compiled a list of activities that providers can complete to fulfil their Improvement Activity score. Certain activities are ranked high-weighted (20 points) and some are ranked medium weighted (10 points). To earn full credit for MIPS Improvement Activities, providers have the option to complete a variety of activities with a goal of 40 points. The providers at the Healthcare System earn double points for their activities since they are considered to have Special Status. This status is received by providers working in a Health Shortage Area (HPSA). Among the 118 Improvement Activities offered, the Healthcare System's providers participate in the following three activities: Engagement of patients and families to guide improvement in the System of Care (PROs, High Weight), engagement of patients through implementation of improvements in Patient Portal (Patient Portal, Medium Weight), and regularly assess the patient experience of care through Surveys (Surveys, Medium Weight). Thus, these are the three activities that will be evaluated as a part of this project. Procedure To determine each group's Improvement Activity Score for January, the following datasets were requested and used for analysis: A. Complete list of providers and their associated group: The Healthcare System's Quality Department provided an excel file (File A) that includes a list of providers and their assigned group as of January 2020. The list included 2,127 providers across eight different provider MIPS Improvement Activities 7 groups. This list was used to compare to the Patient Portal, PROs, and Surveys lists provided by other hospital departments to determine what groups are successfully completing their Improvement Activities. B. Providers using the Patient Portal: After submitting an online request, the Enterprise Data Warehouse (EDW) team provided an excel file that included a list of 1,626 providers that used the Patient Portal during the month of January. To determine the proportion of providers within each group using the Patient Portal (desired system) versus mEVAL (current system) to capture PROs, provider information was examined line-by-line compared to File A. C. Providers using PROs in their practice: Upon request, the Healthcare System's Medical Group Analytics team provided an excel list of the 543 providers using PROs Instruments for the month of January. In order to establish a percentage of providers using PROs in each group, Conditional Formatting was completed in Excel to compare the PROs data to File A. D. Providers using Surveys in their practice: After online request, an Excel file with a list of providers using Patient Experience of Care Surveys was provided by the Exceptional Patient Experience Department (EPE). The 931 providers in this Excel sheet were compared line-byline with File A to determine how many providers in each group are successfully completing Patient Care Surveys. Analysis To describe the proportion of providers that use the Patient Portal, the list of providers using the Patient Portal was compared against the list of all providers (File A). Then, the providers were grouped by service, and the rate of usage within each group was calculated. A MIPS Improvement Activities 8 similar strategy was used to compare the files about PROs use and Survey use with File A. After matching the files using provider name, the proportion of PROs use, and Survey use was calculated for each group. These analyses were performed using Excel functionality to match text using conditional formatting and to calculate percentages using pivot tables. To interpret the usage rates observed, two strategies were used. First, the expectation was that at least 50% of providers should be using each of the desired activities. Second, the usage rates for the three activities are an input for calculating the Improvement Activity Score. To calculate the Improvement Activity Score, the following logic was used: Improvement Activity Score calculation is based on the weight and scores for each Activity. • PROs (High Weight Activity) = 20 points • Patient Portal (Medium Weight Activity) = 10 points • Survey Use (Medium Weight Activity) = 10 points Since the providers at the Healthcare System are considered to have Special Status, all of the Activity Scores are doubled creating an Adjusted Improvement Activity Score. If the provider groups total Activity Score is 40 points or more, they will earn full points for their Improvement Activity Performance Score. Methods for improving provider groups Improvement Activity scores were discussed with the Quality department. We reviewed dilemmas of previous approaches and what might work in the future for all providers at the Healthcare System in addition to individual provider groups. MIPS Improvement Activities 9 Ethical Aspects The Quality Department has demonstrated integrity and ethical considerations at all stages of the capstone project. Their methodologies portray a constant consideration for providers and patients alike while discussing their research methods. It is evident that they have the best interest for the institution and patients correspondingly. This project does not require Institutional Review Board (IRB) approval because it does not involve human subject research. Provider data was reviewed which is not private information. This paper was deidentified to protect the academic hospital and the provider groups personal information. Usage Rates Results Provider groups using the Patient Portal was the only Improvement Activity across all service groups successfully completed more than 50%. However, four of eight of the provider groups still met the 40-point Improvement Activity score goal to achieve full Medicare reimbursement. As shown in Table 1, among the 2,127 providers evaluated, 1,1185 used the Patient Portal during the month of January. Five of the eight service groups met the ≥50% target use of the Patient Portal. The usage rates provide information about how many providers need to switch to the Patient Portal before mEVAL can be replaced. Currently, there is not an end date for mEVAL, but the Quality Department is making a push to transition aimed at improving patient data procurement and communication. Table 1 shows that 543 of the 2,127 providers used PROs in their practice. Only two groups exceeded the 50% target completion rate. Survey usage demonstrated that 931 out of the 2,127 providers utilized patient Surveys during the month of MIPS Improvement Activities 10 January. Four out of the eight service groups had a 50% or greater completion rate necessary to earn full points towards their Activity Score. Table 1 Description of Improvement Activity usage among providers, by service group - January 2020 Provider Group Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 Grand Total Providers (n) 330 54 94 1204 126 229 64 26 2,127 Patient Portal n (%) 96 (29%) 47 (87%) 45 (87%) 704 (58%) 51 (40%) 172 (75%) 50 (78%) 20 (77%) 1185 (56%) PROs Usage n (%) 45 (14%) 40 (74%) 24 (26%) 260 (22%) 32 (25%) 100 (44%) 27 (42%) 15 (58%) 543 (26%) Using Surveys n (%) 158 (48%) 45 (83%) 32 (34%) 509 (42%) 3 (2%) 135 (59%) 35 (55%) 14 (54%) 931 (44%) Services shaded green have exceeded 50% target. Services shaded red have not met 50% goal Summary of Improvement Activity Scores The data presented in Table 2 illustrates which Improvement Activities each of the service groups have successfully completed and their corresponding Improvement Activity Score. The data indicates that Groups 2, 6, 7, and 8 have all completed the required Improvement Activities to qualify for full credit in this performance category. Groups 1, 3, 4, and 5 all fell below the 40-point Improvement Activity goal. Table 2 Summary of QPP Improvement Activities Scores for each service group, based on data from January 2020 Provider Group Info Provider Group Group 1 Group 2 Group 3 Group 4 Group 5 Providers in Group 330 54 94 1204 126 Improvement Activities Using PROs 14% 74% 26% 22% 25% Patient Portal 29% 87% 48% 58% 40% Survey Use 48% 83% 34% 42% 2% Improvement Scores Activity Score 0 40 0 10 0 Adjusted Activity Score 0 80 0 20 0 MIPS Improvement Activities 11 Table 2 (Continued) Group 6 Group 7 Group 8 229 44% 75% 59% 20 64 42% 78% 55% 20 26 58% 77% 54% 40 Green Box = > 50% Red Box=Below 50% Yellow = Near 50% 40 40 80 Recommendations As shown in Table 2, a subset of provider groups needs to improve their Quality Improvement Activities scores to receive full Medicare reimbursement. After consultation with the Quality Department, a decision was made to handle Group 1 separately because they have data within two Electronic Medical Records (EMR) and participation rates were only assessed within the Healthcare System's EMR. Collaboration and combination of data sets with the separate institution will increase provider participation rates. As shown in Table 3, different strategies will be used for each group due to the variable number of providers and their unique challenges to improve Activity scores. In the past, the Quality Department has been encouraged to avoid troubling providers about completing PROs, Surveys, or using the Patient Portal since they already have busy agendas. This is one area that can be improved since Medicare reimbursements are dependent on the completion of Improvement Activities. Several of the provider groups have Ambulatory Chief Value Officers that oversee the group's activities. Approaching Chief Value Officers with their group's Improvement Activity scores and a plan to increase their scores should be advantageous for reimbursement funds. Providing MIPS status education will be essential to improving Improvement Activity scores within the provider groups. Education about the Quality Payment Program and the Merit-based Incentive Payment System will help clarify any questions providers have about the Medicare based repayment system. Further education about each of MIPS Improvement Activities 12 the Improvement Activities and how the weight-based scoring system functions may contribute towards provider group success. Another suggestion to promote success of all provider groups is to hire educational personnel to provide feedback to each of the provider groups on their quarterly MIPS Improvment Activity scores. These employees could provide Improvement Activity education to provider groups and keep groups on track to meet their maximum refunds annually. Table 3 Summary of goals, recommendations and rational for Improvement Activity Service Group Goal Groups • Maintain current processes 2, 6 7, 8 Group 3 • Improve completion rates of Patient Portal • Focus on completion of PROs usage Group 5 Rationale Provider Groups Meeting Target for January • Educate about MIPS status • Processes are impacting Medicare reimbursement and the current usage levels need to be maintained. Provider Groups Falling Below Target for January • Improve completion • Educate about MIPS status • Have not met the 50% goal for any rates of PROs, Patient Improvement Activities. • Target providers not Portal and Survey • Small group (94). Determine what completing Improvement Use providers are not completing Activities necessary Improvement Activities • Focus improvement on Survey and PROs use Group 4 Recommended Plan • Improve completion rates of Patient Portal and Survey Use • Educate about MIPS status • Increase Survey use by 8% • Increase Survey use by 8% • Largest group (1,204). System-wide process change recommendation. • System-wide process change mandating completion of top two used PROs (PROMIS Physical function and PROMIS depression). • Educate about MIPS status • Physician group to complete > 50% PROs • Focus on PROs (High-Weighted Activity) would guarantee a score over 40 if completed. • Small group of providers (126), Investigate providers not completing PROs MIPS Improvement Activities 13 Table 3 (Continued) Group 1 Provider Group Outside of Hospital System • Improve completion • Educate about MIPS status • Group 1 has data within two rates of PROs, Patient Electronic Medical Records and • Collaborate with a separate Portal and Survey participation rates were only assessed institution to develop plan Use within the Healthcare System's EMR. on increasing Improvement Collaboration and combining of data Activities sets with the separate institution will increase provider participation rates. Evaluation Strategies for refining provider groups Improvement Activity scores should be reevaluated every quarter. The data collected for this project was limited to the month of January. After collecting future provider information, data trends will become more evident and Quarter 1 data can be evaluated for necessary improvements. Table 4 displays a quarterly adjusted Improvement Activity score chart that can be used to compare trends of provider groups throughout the year. Table 4 Proposed strategy for summarizing Quarterly Adjusted Improvement Activity Scores Provider Group Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 Jan 0 80 0 20 0 40 40 80 Q1 Feb Mar Q2 Q3 Q4 MIPS Improvement Activities 14 Discussion Working with the Quality Department, it was determined that calculating provider groups usage of MIPS Improvement Actives was necessary to establish a baseline for future comparison. These figures provided the Quality Department with exact percentages of what Improvement Activities each provider group was completing. The new information about Improvement Activity scores permitted separate recommendations for each provider group to increase scores. A quarterly reevaluation system was endorsed to determine if suggestions for Activity Scores were efficacious. Future data analysis of each provider groups Improvement Activities will determine if recommendations were beneficial or if the Quality Department needs to take a different approach to increasing scores. Limitations Due to time restraints and lack of access to data, only one month of provider group data was analyzed for this project. The results for January may not reflect groups completion rates for the remainder of the quarter. This was discussed with the Quality Department and plans to analyze data will continue when data is provided by each owner. Conclusion Providers at the Healthcare System have elected to participate in Merit-based Incentive Payment System under the Quality Payment Program which was adapted to improve quality, promote interoperability, improve care process, and cost of care. This project demonstrated the importance of Improvement Activities and validated their importance to improving the care process, enhance patient engagement in care, and increase access to care. MIPS Improvement Activities 15 While the benefits of MIPS are evident, there are still needs for advancement in most provider groups Improvement Activity scores. After analyzing PROs instruments, Patient Portal, and Patient Experience of Care Surveys information for the month of January, only 50% of provider groups had the required 40 points for complete Medicare reimbursement. Detailed strategies for each group were provided to the Quality Department to address the deficiencies regarding MIPS Improvement Activity Scores. Evidence of successful recommendations will be apparent as future data is collected and compared to January's analysis. MIPS Improvement Activities 16 References Al-Abri, R., & Al-Balushi, A. (2014). Patient satisfaction survey as a tool towards quality improvement. Oman medical journal, 29(1), 3-7. https://doi.org/10.5001/omj.2014.02 Black, N., Burke, L., Forrest, C., Ravens Sieberer, U., Ahmed, S., Valderas, J., … Sieberer, U. H. R. (2016). Patient-reported outcomes: pathways to better health, better services, and better societies. Quality of Life Research, 25(5), 1103-1112. https://doi.org/10.1007/s11136-015-1168-3 Bresnick, Jennifer. (2016). Why Aren't Hospitals Using Patient-Reported Outcomes Data? HealthITAnalytics. https://healthitanalytics.com/news/why-arent-hospitals-usingpatient-reported-outcomes-data CMS (2020). MIPS overview. Retrieved from https://qpp.cms.gov/about/qpp-overview CMS (2020). MIPS Individual or Group Participation. 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