CPIA: More Than MACRA Leftovers!

The Monday after Thanksgiving. Festive celebrations with family, large meals, a bit of football, and perhaps some shopping on Black Friday are all now in the rearview mirror. It’s Monday and we are left with, well, leftovers. One week ago Dugan Maddux provided us with a brief reprieve, but today it’s back to the MACRA salt mines. On the MACRA menu today is the new kid on the block; the kid formerly known as Clinical Practice Improvement Activities now has a new name—simply Improvement Activities.

Beyond the name

Although CMS shortened the name, Improvement Activities remain an important component of MIPS. How important? Fully 15% of your MIPS score will originate from Improvement Activities. Resource Use is a no show next year, which makes this new kid the third most important MIPS category from a scoring perspective, just behind the 25% you will receive from Advancing Care Information and quite a ways behind Quality, which commands a whopping 60% of your score in 2017.

Easy button

Let’s not forget, however, that next year is a transition year. As we recently noted, those of you facing MIPS next year can simply dip your toe in the water and avoid the 4% haircut in 2019. One of the easiest ways to do that is to attest to the fact that you participated in a single Improvement Activity during an appropriate time interval next year—but more about that later.

What is an Improvement Activity?

Let’s cut to the chase. What in the world is an Improvement Activity? Wonderful question, without a clear answer. Let’s try to answer it by borrowing text from the CMS website: “In this new performance category for 2017, clinicians are rewarded for care focused on care coordination, beneficiary engagement, and patient safety.” Crystal clear, no? The final rule goes on to state that “Section 1848(q)(2)(C)(v)(III) of the Act defines an improvement activity as an activity that relevant eligible clinician organizations and other relevant stakeholders identify as improving clinical practice or care delivery, and that the Secretary determines, when effectively executed, is likely to result in improved outcomes.” Effectively CMS has pulled together a list of 92 (yes, 92) activities, which in their view will lead to improvement in the care you provide to Medicare beneficiaries. I’d list them all here but you would never make it to the end of the blog (where the enlightening part of this post resides). Instead check out this webpage, which includes the list along with a brief description of each activity.

Weighting and scoring

Not to complicate matters (this is CMS after all), but there are basically 2 flavors of Improvement Activities: those weighted heavy and those weighted medium. This is important for those of you planning to run the full MIPS gauntlet next year. The heavy-weighted activities are worth more MIPS points than the medium-weighted activities. To be more specific, the heavy weights are worth 20 points and the medium-weighted Improvement Activities are worth 10 points. Per the final rule, you need to achieve 40 Improvement Activity points in order to capture the maximum number of points available within the Improvement Activities category of MIPS. What could be simpler?

But wait, there’s more! If you find yourself in a “small practice,” which CMS defines as 15 or fewer providers, or if you practice in a rural area or a geographic HPSA (health professional shortage area), or if you are a “non-patient facing” MIPS eligible clinician (like a pathologist), you basically receive double credit for your efforts (you achieve a maximum score for a single heavy-weight or 2 medium-weight Improvement Activities). Last but not least, next year some of you will be participating in an Alternative Payment Model (like a track 1 MSSP ACO). Simply by participating in the APM, you will receive half credit for the Improvement Activity category of MIPS. Could they make this any easier?

Let’s try to summarize this mess.

1. If you are part of a large group (16 or more providers) and you are not in a rural area or a HPSA, you can collect the maximum Improvement Activity category points by performing either 2 heavy-weighted Improvement Activities, 4 medium-weighted Improvement Activities, or 1 heavy-weighted and 2 medium-weighted Improvement Activities
2. If you are part of a small practice (15 or fewer providers) or you work in a rural area or a HPSA, you can collect the maximum Improvement Activity category points by performing either 1 heavy-weighted Improvement Activity or 2 medium-weighted Improvement Activities
3. If you are a participant in an APM, you automatically receive 20 of the possible 40 Improvement Activity points, which means you only need half of what I outlined in numbers 1 and 2 above.

All together now

So how is this supposed to work? First determine where you find yourself in 2017 on the MIPS pick-your-pace continuum below.

As Acumen blog readers, clearly none of you are in the red circle at the far left. The Easy Button referenced above is next in line (i.e., Submit Something) and this is where I suspect many of us will land next year. Simply locate one of the 92 improvement activities on this CMS web page and put that activity in place for any continuous 90-day period during CY 2017.

If you are a bit bolder and are looking at either the Partial or Full Year circles on the right in the graphic above, remember, you are only compelled to engage in your selected improvement activities for any continuous 90-day period, even if you are participating in MIPS for the entire year.

Of course when you have finished your work here, you need to get credit for all of that improvement activity. You do this next year by attesting to the fact that you did indeed participate in said Improvement Activities for a continuous 90-day period in 2017. CMS will allow for submission of data for the Improvement Activities performance category using the qualified registry, EHR, QCDR, CMS Web Interface, and attestation data submission mechanisms. There are indeed a large number of options available to let CMS know that you’ve completed the work.

By the way, buried in the depths of this final rule is a bit of fresh air. The continuous 90-day engagement period for Improvement Activities remains in place for 2018. Seems odd to me, but there you have it. When you attest you are basically stating you’ve participated in the improvement activity for 90 straight days in 2017, and that’s apparently enough in 2018 as well.

Last but certainly not least, as you may recall from Diana Strubler’s outstanding deep dive into Advancing Care Information, there are some Improvement Activities that will count in the ACI bonus section. Unfortunately those are not clearly marked in the web page I referenced. They are however readily viewable in Table H within the final rule itself.

Pass the turkey…

As complicated as our friends at the Agency have managed to make this, the Improvement Activities category of MIPS is actually going to be one of the easiest parts of the program. My advice would be to look at the pick-your-pace graphic above and determine which circle you wish to live in next year. Then identify one or more Improvement Activities that you believe will make a difference. Pick a date next year prior to October 2, 2017, and set the wheels in motion for at least 90 days. If I were running the MIPS gauntlet next year, Improvement Activities would not keep me up at night like those Thanksgiving leftovers certainly do.

What are your thoughts about the new kid on the block? Drop us a note and join the conversation.

Terry Ketchersid, MD, MBA, practiced nephrology for 15 years before spending the past seven years at Acumen focused on the Health IT needs of nephrologists. He currently holds the position of Chief Medical Officer for the Integrated Care Group at Fresenius Medical Care North America where he leverages his passion for Health IT to problem solve the coordination of care for the complex patient population served by the enterprise.

Top image from www.canstockphoto.com