CMS Recognizes Oregon PCPCH Program as Part of "Improvement Activity" Required in the MIPS Program

January 7, 2017   |  Tags: Blog   |  Tags: alternative payment , OHA PCPCH , Payment , Payment Reform
David Smith, MBA

If you are a Medicare provider, you may be aware of the new MACRA program, as it was called when legislated, and now known as the Quality Payment Program (QPP). The QPP repeals the Sustainable Growth Rate formula and in its place establishes two tracks for providers to choose from: the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Models (APMs).

MIPS has four categories, which you can review on the CMS QPP website. One of the categories is “Improvement Activities,” in which clinicians are rewarded for care focused on care coordination, beneficiary engagement, and patient safety. This category includes 93 Improvement Activities (others may be added). Clinics are required to achieve 40 points to meet this objective. This can be satisfied in several ways—one of which is to be a patient-centered medical home (PCMH). The rule calls out several national PCMH initiatives, and the Oregon model is specifically mentioned, which will be helpful for practices who have undertaken this initiative. Other approaches to MIPS involve participation in initiatives that HealthInsight Oregon can assist with, including the Million Hearts cardiovascular health campaign, the prescription drug monitoring program (PDMP, with two activities listed), and the Diabetes Self-Management Program (six activities listed). The rule lists many other activities that may relate directly to work you are already doing. Physicians in groups smaller than 15 providers only have to do two activities; physicians in larger groups will need to do four activities.

CMS has expressed support for the Oregon-based Patient-Centered Primary Care Home (PCPCH) program as it relates to the MIPS incentive program. Although PCPCH won’t give you credit to satisfy all four MIPS categories, it does give you complete credit for the “Improvement Activity” component of the MIPS. Regarding the final rule, the Oregon PCPCH program has released the following to support their integration.

In the final rule, CMS has expanded the definition of how they will recognize MIPS eligible clinician or group to a certified patient-centered medical home or comparable specialty practice to include certification from a national program, regional or state program, private payer or other body that administers patient-centered medical home accreditation. This applies to PCPCH recognition! Please see page 17, Improvement Activities (ii) of this executive summary

To help you understand how you can use PCPCH to satisfy the Improvement Activities requirements, here are the essentials from the QPP web page on Improvement Activities:

Instructions

1. Review and select activities that best fit your practice.

  • Most participants: Attest that you completed up to 4 improvement activities for a minimum of 90 days.
  • Groups with fewer than 15 participants or if you are in a rural or health professional shortage area: Attest that you completed up to 2 activities for a minimum of 90 days.
  • Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model: You will automatically earn full credit.
  • Participants in certain APMs under the APM scoring standard, such as Shared Savings Program Track 1 or the Oncology Care Model: You will automatically be scored based on the requirements of participating in the APM. For all current APMs under the APM scoring standard, this assigned score will be full credit. For all future APMs under the APM scoring standard, the assigned score will be at least half credit.
  • Participants in any other APM: You will automatically earn half credit and may report additional activities to increase your score.

2. Download a CSV file of the activities you have selected for your records.

A provider’s suggested performance of up to either 4 or 2 improvement activities depends on how many providers are in the practice and whether or not they are in a rural area or health professional shortage area. Although PCPCH will obviously help primary care providers, specialty care providers will be able to count credit in a combination of up to 4 or 2 of 93 “Improvement Activities” to qualify for this part of MIPS, including Million Hearts, self-management education programs, and others.

Disclaimer: This article focuses on only one of the four categories for MIPS. Make sure to consider your participation in the other four categories and understand the minimum requirements for participation.

For more information, please reach out to us at Healthinsight Oregon, your state-based Medicare Quality Improvement Organization. You may email us at dsmith@healthinsight.org, or call (503) 310-8629.

This material was prepared by HealthInsight, the Medicare Quality Innovation Network-Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.  
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David Smith has worked in quality improvement and health care technology roles over the past 18 years. He recently helped an EHR company certify their product for ONC Certification. Additionally, he worked for HealthInsight for 4 years performing quality improvement work, led education and outreach efforts for meaningful use and worked on next stage interoperability under the national Beacon grant. He has an MBA from Westminster College and a BA from Brigham Young University.