Four Things to Consider When Choosing a MIPS Reporting Method

August 23, 2017 Shelby Harrington

As providers across the country look to verify their status as a 2017 Merit-based Incentive Payment System (MIPS) eligible clinician and determine how to report for MIPS, the next question is which reporting vehicle works best.

Though there are numerous options offering clinicians the opportunity to leverage a reporting mechanism that meets the needs of their practice(s), limited information exists to help providers choose what’s right for them. Without information to compare and contrast reporting mechanisms, the selection process becomes burdensome and overwhelming.

Because MIPS Advancing Care Information (ACI) and Improvement Activities (IA) reporting categories are essentially the same across the board, outlined below are four key questions to consider when choosing a quality reporting method.

What measures apply to your clinical practice?

Each reporting method offers different measures, ranging from the prevention- and chronic disease management-focused measures in the CMS Web Interface option to the hundreds of custom measures available in Qualified Clinical Data Registries (QCDRs). And, MIPS data will be publicly posted on Physician Compare, so it’s important to consider how these measures will portray the clinical practice of each provider.

While all reporting platforms may be suitable for primary care providers, specialists may only find reportable measures in QCDRs. For some sub-specialists, this becomes an exercise in determining which measures can be reported versus preference on what to report if there aren’t available measures related to their area of expertise. While this has become less of a problem with the growth in QCDRs, the challenge still exists.

How feasible is data collection?

Each reporting method varies in the types of data sources that can be used, ranging from billing and quality data codes on Medicare Part B claims to clinical data solely from electronic health records (EHRs) to manually abstracted registry inputs.

Ask yourself:

  • What data sources are currently in place and how accessible are the records?
  • Can the EHR(s) produce quality data extracts?
  • Can reports be extracted from the billing/claims system?

For some practices, the least burdensome option for collecting accurate data is manual, either by concurrently collecting the necessary data elements within your practice workflow, or assigning a team member to retroactively abstract the measures.

Which method gives you the highest scores?

Strategically selecting a reporting method and measures for the quality category is key to maximizing a MIPS score. With the benchmark data from CMS available for most reporting methods and measures, providers should track and compare their performance on more measures than they are required to report so they can select the method and measures that will earn the most points.

For many specialists, this makes the QCDR method more attractive. Clinicians can choose a QCDR tailored to their specialty and focus on improving in areas that align with their clinical practice.

Another way to maximize scores is to leverage reporting methods that offer bonus points or points across multiple categories. For example, up to 10 bonus points may be awarded for reporting quality measures using Certified Electronic Health Record Technology (CEHRT) for end-to-end reporting. Note this bonus is not exclusive to the CEHRT reporting, but can also be earned for reporting measures, such as Electronic Clinical Quality Measures (ECQMs), through other mechanisms, including QCDRs and Registries.

Which method best aligns with your organization’s quality strategy?

The logistics and details of reporting often overshadow the ultimate goal of MIPS, which is to improve the quality and value of healthcare. It’s important to think about how MIPS reporting can align with a practice or organization’s quality goals and improvement processes.

Consider whether a reporting method offers measures your practice is focused on for other initiatives, such as patient-centered medical home certification or disease management programs. Or does a reporting method offer measures that align with your practice’s performance-based compensation plans?

It’s also important to note whether the reporting method supports continuous quality improvement by generating consistent performance feedback. For example, the CMS Web Interface provides a one-time snapshot at the end of the year, but QCDRs and Registries provide regular performance reports throughout the year.

A successful approach to MIPS requires using a reporting mechanism that balances the unique characteristics of a practice with program requirements to find a solution that maximizes scores, minimizes administrative burden and improves care.

For more information about choosing the MIPS reporting method that’s right for you, click here.

Author information

Shelby Harrington

Shelby Harrington

I’m a National Director of Quality for Premier, based in the Washington, DC area. A nurse by background, I’ve spent most of my career in quality improvement, patient safety and healthcare informatics.


The post Four Things to Consider When Choosing a MIPS Reporting Method appeared first on Action For Better Healthcare.

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