CME that Counts for MIPS Webinar

Published Date

This is a recording from the Accreditation Council for Continuing Medical Education (ACCME) and Centers for Medicare and Medicaid Services (CMS) webinar held on March 6, 2019. 

Download the slides below.


  • Graham McMahon, MD, MMSc, President and CEO, ACCME 
  • Molly MacHarris, Program Lead for the Merit-Based Incentive Payment System (MIPS) at the Centers for Medicare & Medicaid Services 
  • David Nilasena, MD, MSPH, MS, Chief Medical Officer for the Dallas Regional Office at the Centers for Medicare & Medicaid Services
  • Angela Foster, MBA, MS, Health Insurance Specialist at the Centers for Medicare & Medicaid Services 


  • 1:49 – ACCME Introduction
  • 9:55 – MIPS Overview
  • 25:20 – Reporting Options and Data Submission
  • 37:38 – Improvement Activities
  • 50:37 – Question and Answer

>>SINGER: Good afternoon and welcome to the CME Accounts for MIPS Webinar, together with CMS. We're very happy to have you today. Thank you for joining us. All lines are muted at this time due to the number of people that have dialed in, and we'll get started now. My name is Steve Singer. I'm the Vice President for Education and Outreach. Just a few housekeeping notes. This webinar is being recorded so that we can provide to you the opportunity to view an archive at a later time. And we are delighted that so many of you during the registration process, submitted questions and ideas for us. We've reviewed them, and we'll address those questions a little later in the webinar. The questions box will be open if you want to share comments or feedback with us, but again, the lines will be muted, and again, we thank you for your participation. I want to just share, really quickly, a little information about the folks that are on the webinar. We have more than 480 sites registered, and we're really excited that there's such a diversity of the accredited CME provider community that is on the call today, and really looking forward to sharing how we can help to support you with this information.

On the call today, your faculty are going to be, Graham McMahon, who is our President and CEO at ACCME, and we're also very happy to have Angela Foster, David Nilasena, and Molly MacHarris from the Center for Medicare and Medicaid Services. So, with that, I'm going to hand things over to Graham to get started. Thank you.

>>McMAHON: Thanks very much Steve, and hello everybody on the line. This is Graham here. We'll at least have a chance to chat with you and explore, and explain, some of our collaborations at CMS around the MIPS program itself. As you well know, we've been working to support you and the evolution of continuing education, so that it supports practice improvements, supports safe and effective care for the patients we all serve and our community serves. And that involves evolving our approach to education from knowledge transfer, to practice improvement, specifically, from just about learning, to helping to change behavior, moving from satisfaction as a primary metric of our success, to demonstrated outcomes for the interventions that we plan, and the activities that we create. In order to do that, that means moving away from our typical approach of doing one and done speaker-based programs, to longitudinal curriculum, and performance improvements programming that drives quality, more collaboration from, not just the CME unit, or an education unit, planning and delivering activities, but working with QI, working with patient safety, working with data analysis, working with other extenders of our work, so that we can be effective. And also, of course, moving beyond uni-professional, or uni-disciplinary, activities into team-based activities that facilitate the evolution of, and the performance of, the healthcare team.

To do that, we've been collaborating with CMS, and others, to help support you, and the creation of this improvement activity under the ACCME process of accredited CME, is part of the answer to try and make sure your work is recognized through the credits you're able to freely issue. We know that there are many questions about this. Some of the questions can be broadly summarized in these four theme, but we literally received hundreds of questions, and we will be deliberating on some of those after I give you some introductory remarks. Excuse me. And as well as that, we'll have more information and references on our website to help support you, and ensure that you're able to do your work. This does however, represent a key opportunity for Accredited CME providers. Obviously, you're very facile with, and comfortable with, issuing CME credits for your work in education and educational development. After this program, you'll be able to begin to deploy programs that also meet the expectations of the MIPS program and improve the activities within it. Those same activities can count for either part two, or part four, of MOC, or now what's referred to as continuing board certification, but are also, if you're at an institution, like a healthcare organization, might help you meet the expectations from the Joint Commission and others, for performance improvement that's individualized, whether that's remediation, or otherwise, through the OPPE or FPPE.

This is also a key opportunity to nurture together this process of improvement through what we hope you're creating in an educational home for your learners. Learners feel compelled to, and respond to, organizations that they trust and educators that they have a relationship with. The more in which you can support their work to improve their practice, improve their processes, improve their learning, create teams, facilitate leadership and development, the more likely it is that you will be successful as an educator and have impact. So, we're hoping that this process of being able to digitate with the quality improvement work going on in organizations will help you nurture this concept of an educational home for your learners, that facilitates reflection improvements, facilitates and fosters interprofessional learning, engages them in QI, and in doing so, by addressing issues that are relevant to them, and moving out of compliance-based education, we can help reduce burnout and bring more joy to practice.

This is a busy slide with the key elements of the improvement activities that are required and the elements to meet the expectations of CMS, and they're pretty straight forward and familiar to you as CE providers. We want you to create a program that addresses a quality or safety gap, where there are specific aims for improvements. There are interventions that are designed to improve something, where there's an analysis of performance data to assess the impact of those interventions, and where there is meaningful clinician participation as monitored by you. Of course, these are all highly familiar components of an educational intervention, or a performance intervention for CE providers, because they meet the expectations of the accreditation requirements as well, and similarly, they meet the expectations for MOC, and OPPE, and FPPE, because they reflect best educational practices. We're going to come back to the specifics of each of these a little later in the webinar, so that we'll look at them more closely and help answer and anticipate your questions.

A key part of getting started though is bringing together some people who can help you and advise you, but a really important part is making sure that improvement activities are relevant and meaningful for the individual clinician. And you can do that as a big society, you can do that as a small hospital, you can create relevant and meaningful activities for your community by asking clinicians what do they want to improve. And, in many cases, clinicians are astute observers of barriers to performance and quality in their care environment, and because CE professionals are so disseminated around the country, in institutions big and small, in societies big and small, in educational companies and others, they can help facilitate the answers to those questions, and then help the clinician, and support the clinician, in building programs to help them meet quality objectives.

This is a key differentiator for what makes improvement activities under this umbrella different from many of the activities listed on the MIPS website, 'cause they allow the clinician, and the clinician's team, or their society, to work with their community to identify what's maximally relevant to them, and use a process that is content naïve to be able to meet the performance expectations for CMS. Lastly, it's just worth recognizing that these same expectations are valued by the boards. As listed here, you can meet the expectations for Part two and Part four for Internal Medicine, Ophthalmology, Otolaryngology, and Pathology through this process, and as genealogy in pediatrics in Part 2 programming. And these are collaborations that we continue to expand and evolve so that they're synergized between the expectations of organizations like CMS, ACCME, and from the boards. That's a very brief introduction to what we're going to talk about in more depth and I'm going to pass it over to my colleague at CMS, Molly MacHarris, and take it away, and then we'll come back to some of the specific questions, and the specific action items for CE providers at the end of her comments. Molly.

>>MACHARRIS: Thank you Graham, and thank you everyone for being here with us today. My name again is Molly MacHarris, I work at CMS, in the Center for Clinical Standards and Quality. I'll be going over the basics of the mid-year three final rule and our policies, along with my colleagues Angela Foster and Dr. David Nilasena. So, we actually, have a lot of content that we want to cover with you guys today, and we only have an hour to do it in. So, let's go ahead and jump right in. So, if we can move on to the next slide, and then the next slide again. So, just some of the basics of what we'll be covering. Again, as I mentioned previously, I'll be focusing on our year three policies and the ways that you can participate. So, let's go ahead and move on to the next slide, and then to the next side again. So, let's first start with some of the basics. I suspect most of you are already familiar with the basics of the quality payment program, but just in case there's some of you who are not, let me just spend a few minutes going over this.

So, the Quality Payment Program is a program that applies to clinicians who render services under our CMS' physician fee schedule, under the Part C methodology. Under the Quality Payment Program, there are two tracks that you can participate in. The MIPS track, which I'll be talking about along with my colleagues Angela and David here on today. We also do have the advanced alternative payment models track. Again, we won't be getting into that side of the quality payment program, but if you all are interested in participation in an APM, I would highly encourage you to go to our website, and we have a lot of information there. But so, prior to the Quality Payment Program and the law that authorized it, the MACRA law, what was impacting clinicians were three legacy programs that included the physician quality reporting system or PQRS program, which focused on quality, the physician value modifier program or VM program which looked at quality and cost, and then the Medicare EHR Incentive Program for eligible professionals, which dealt with the usage of certified EHR technology.

As you'll see in the coming slides, and again, for those of you who are familiar with the Quality Payment Program, those elements are... Or parts of those elements have continued on under the Quality Payment Program, but we're looking at how the things that we ask you to do, clinicians, differently under this new program. So, let's move on to the next slide. Some of the things that we took into consideration when we were developing the quality payment program were the strategic objectives. So, as you can see on the slide here, we have seven strategic objectives. There's a lot of sub-information that we track to internally, here at CMS on how we're meeting these objective, but most importantly, the program is all about improving beneficiary outcome. We really feel it's critically important that patient's outcomes are improved, particularly through patient-reported outcome measures, patient experience, patient survey.

So, that's the lens that we are constantly looking at as we are developing our policies. Additionally, we feel it's critically important that we enhance the clinician experience by reducing burden on all of you. We recognize that under the legacy programs, there are a lot of things that we ask you all to do. So, that's something that we're constantly looking at as we develop new policies, and as we look at the trajectory of clinicians under the Quality Payment Program. So, let's go ahead and move on to the next slide, and then the next slide again, to start digging into the specifics of the MIPS program.

So what is MIPS and what does it do? MIPS is a program that assesses clinicians' performance on four performance categories. And as you can see on the slide here, those four categories include quality, cost, improvement activities, which we're going to spend a lot of time talking about here today on improvement activities, and promoting interoperability. Promoting interoperability deals with the usage of certified EHR technology. So, what we do is we assess your performance on these four performance categories, and we assign to you something called, a final score. That final score can range anywhere between zero and 100 points. In this third year of the program, we are currently in the third year, we're in calendar year 2019, the number that you want to have your final score be at or above, is 30.

So, again, I'll circle back to this again towards the end of the presentation, but just to say it one more time for now, everyone would ideally like to have their final score at or above 30 points in this third year. So, let's go ahead and move on to the next slide for our high level timeline. So, as I just mentioned, we are in our third year of the MIPS program. We are currently in our performance period. Then, the majority of data submission will occur following the next calendar quarter of next year. So, approximately from January through the end of March 2020, then we would issue you feedback, based off of your performance on those four performance categories, as well as your associated payment adjustment. The payment adjustment is what determines how your claims get impacted, so how much either additional money you'll be receiving, or how much your claims would be reduced, the money we would be taking away. Again, we ideally want people to avoid that negative payment adjustment. So, to do that, you need to have your final score at or above 30 points.

Okay. Let's keep moving on to talk through some of the eligibility basics. So, if we can go to the next slide. So, who can participate in the MIPS program for this third year? So, we do still have our same eligible clinician types that we've had in the first two years, which includes physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. As a reminder, when we talk about physicians at Medicare, we don't just mean MDs and DOs, we also mean dentist, podiatrist, optometrist and chiropractors. So, Medicare we define physician a little bit more broadly than you may think. So, again, it includes MDs, DOs, podiatrists, dentists, and chiropractors. We've also newly added for this third-year, psychologists, physical therapists, occupational therapists, speech language pathologists, audiologists and Registered Dietitian, or nutrition professionals. Let's move on to the next slide to see how you could potentially be excluded. So again, as I just talked about, we have our eligible clinician types. So, let's say for example, you are a cardiologist, that is a type of a MD, so you could potentially be eligible. Then, we would look to see, is there any reason why you would be excluded? So, we have three main exclusions.

The first way that you could be excluded is if you become initially enrolled to Medicare during the performance period. So, if this was the very first time you ever were enrolling in Medicare within our Paycos and NPES system, you would not be required to participate for this given year. You would, however, have to participate in a future year. The other way that you can... The second way that you can be excluded from MIPS is if you significantly participate in an advanced APM. Remember, the advanced APMs is that separate track under the Quality Payment Program. Again, we won't be getting into details on that side of things here today, but again, there's a lot of resources on our website if that's something you're interested in. And then, the third way that you can be excluded, and this is what we spend the majority of time talking about, so I do have a couple of slides here I want to go over with all of you.

Which deals with our low volume threshold exclusion. And so, this deals with the way that you could be excluded from MIPS based off of the way... Based off of the volume of billings that you make, the number of patients that you see, and the number of services that you render.

So, let's talk through those in more detail. So, as you can see on the slide here, you would be included in the MIPS program if you bill more than $90,000 annually, if you see more than 200 patients, and if you render more than 200 services. So, one of the common questions we've received is what is the difference between a patient and a service? So, as I'm sure you can imagine, if you are a clinician, you could have a patient that comes to see you, let's say, five or six times throughout the year. So, when we do our patient threshold count, that one patient would count as one towards your patient count, but the fact that the patient came to see you five times during the year, that would count as five separate services. So, hopefully, that helps clarify the difference between patients and services, but again, happy to take any questions at the end, if there is time for that.

So, let's go ahead and move on to the next slide to talk through what you can do if you are excluded, but you want to participate in MIPS. So, if that were to happen to you, there's two main option. The first is that you can just volunteer to participate, which means you can report, and perform, on the four performance categories that I mentioned previously, quality, cost, improvement activities, and promoting interoperability, and send us your data. What that means, however, is that if you are not a MIPS eligible clinician and you choose to volunteer is that you would not receive any of the MIPS payment adjustment, either the ability to get more money, so a positive adjustment, or the negative adjustment, a reduction in money.

The other way that you can decide to participate if you're excluded is if you meet one, or two, of those low volume threshold elements I just talked about. You can decide to opt-in. So, let's go ahead and jump to the next slide and I can talk through this in more detail. So, the ability to opt-in, based off of how the low volume threshold applies to you, this is new for this third year. So, let me talk you through this table in more detail. So, starting at the bottom row first, the green row. So, this is the example I talked about earlier. So, you bill more than $90,000 annually, you see more than 200 patients, you have more than 200 services that are rendered. You are required to participate, you are a MIPS eligible clinician, that means that you have the ability to earn a positive adjustment which can increase the money you can get on your claims in the 2021 payment year, or if your final score is below 30 points, that means you would get a negative adjustment. Again, we want to avoid that for as many folks as possible.

Then, looking at the top row, the red row. So, this is if you fall below all three of those elements. So, if you bill less than $90,000 annually, you see less than 200 patients, and if you render less than 200 services. If all three of those are true, then you are excluded from the program, you would not be considered MIPS eligible, which means you would not get the potential money associated with it. You can just choose to volunteer to report, or you can do nothing, but the people that could opt in, are those that fall in those yellowish rows in the middle. So, that would account for a scenario where, let's say, you're a cardiologist, and you provide $100,000 in billings in a year, you see 300 patients, or let me give a different example. You bill $100,000 in billings a year, you provide 300 services, but you only see 100 patient. So, in that scenario, you've met two of the low volume threshold elements, but not all three. So, you can choose to opt-in. What... If you are considered to be an opt-in eligible clinician, once you make the decision that you want to opt-in, it is irrevocable which means that it cannot be changed.

So, I recognize that this is a lot of information, something new that we're offering you to do in this third year, so please stay tuned for additional information that we'll be releasing in the next few weeks, to months, on ways that you can opt into the program, if you chose to do so. So, let's go ahead and move on to the next side to talk through our determination period. So, as I've been talking about here when we talk about the low volume threshold, I've been saying it's based off of your annual billings, the total number of patients you see annually. When we say... When I say annually, I do refer to a fiscal year. So, we've updated in this third year the time frames that we look at for this determination. So, we actually look at two different fiscal years. The first, as you can see on the right hand side of the slide, falls from October 2017 through September 30th, 2018, and then the second fiscal year determination runs from October 2018 through September 30, 2019.

And as reflected on the next slide, we actually load all of that information into our participation status tool on our website. So, you'll hear myself, and my colleagues, mention this website numerous times throughout this presentation. I think I've mentioned it a couple of times already, but I would highly encourage all of you, if you have not yet gone to to please do so. We have a lot of information on there, a lot of resources, and tools, that we've worked with many of you on developing to ensure that it meets your need. So, we do have the year three eligibility information up today. So, if you go to our website and you enter in your 10-digit NPI, we would be able to tell you based off of each of your associated practices whether or not you would be eligible. I know there was a lot of information, and we're just talking about eligibility at this point. So, let me go ahead and turn the presentation over to my colleague, Dr. David Nilasena, to start talking through some of our reporting options and data submission option. David.

NILASENA: Okay, thanks Molly. So you've just heard how clinicians and groups can figure out if they are eligible for MIPS or if they have the ability top 10 and therefore participate in MIPS. So next we'll talk about how you participate in MIPS, and then a little bit later about the specific requirements for each of the four categories.

So, next slide. Alright, so first in MIPS, you can participate in one of three ways, you can do it as an individual clinician. And so we define this as a unique combination of a Taxpayer Identification Number in an NPI number. You can also participate as a group and for MIPS we define groups as a single 10 and all of the NPIs that reassign their billings to their 10, or in some cases and what we call an APM entity, and this can be more than one 10 that are participating in an alternative payment model.

And then finally for starting last year and continuing this year, you can participate as a virtual group and this is a way that several 10s that have 10 or fewer clinicians under each 10 can combine together to participate collectively as a virtual group and therefore be scored as a unit instead of as 10, as individual small 10s.

Next slide. Alright, so now this is my talks about the way that you can get data to us and we've changed this, we haven't changed what actually available to clinicians and groups, but we have changed the way that we talk about it to be a little bit clearer. We used to talk about something called submission mechanisms, and this combined the concepts of sort of who was submitting the data, and what data was being submitted and sort of the form of the data. And we've changed that, starting last year and this year to refer to something called collection types and this refers to the specific types of measures or activities that are being reported. Then we also have submission types, and this is the method by which you get the data to us, sort of the way that it is submitted. And then finally we have submitter types, and so this is who is actually sending the data. It can either be the clinician or group or someone on behalf of the clinicians or group. And we think that this terminology will make things a little bit clear in terms of understanding the options that are available.

Next slide. Alright, so this slide shows the options that are available for individual clinicians, who are reporting for MIPS. You'll see in the quality category, it's the only category that has more than one collection type, and so for quality, we have ECQMs, we have MIPS, clinical quality measures, we have QCDR measures and we have Medicare Part B claims measures. These are only available to those who are in small practices of 15 or fewer clinicians. The submitter types for individuals can be the individual himself or through a third party intermediary. And then the submission typer quality can be what we call direct submission and this is using an API or advanced programming interface. We also have an ability to log in and upload data for quality and then the Medicare Part B claims are submitted on the claims forms.

For the cost category, there's actually no additional data submission required for this category. All of this is derived from your Medicare Part B claims. The improvement activities have again both individual and third-party submitter options and also the direct login and upload options, but also it has an option called login and attest and this is a very simple method of reporting your improvement activities. And then, finally for promoting interoperability, which deals with the use of certified EHR technology. Again, you can report, the individual can report or use the third-party intermediary and it has the same options as we saw for the improvement activities including the login and attest.

Next slide. This slide shows the options that are available for groups and basically it is the same except for the quality category and in the quality category, we have a couple of additional collection types. We have the CMS web interface measures for groups, we also have the CMS approved survey vendor measure for the CAP survey, and for larger groups we have an administrative claims measure, which is the all-cause readmission measure, and then the additional submission type relates to the web interface. And then also I guess the CAP survey, but otherwise everything on this slide is the same except it pertains to groups.

Next slide. Alright, so now we're talking some at a high level for each of the performance categories and we'll save improvement activities for last and Angela will go into a little bit more detail on that.

Next slide. Alright, so first we'll talk about the reporting or performance periods for each of the categories. Now, these haven't changed from year two and for the quality and the cost categories, there is a 12-month reporting period. So you need to submit your quality measures for a 12-month calendar year period and the cost measures are again calculated for you, but we use the same 12 month period. The improvement activities have a 90 continuous day reporting period during the year and the same for the promoting interoperability category. These need to be reported to reflect a 90 continuous day period during the calendar year.

Next slide. This slide shows the weights that are associated with each of the four categories. Molly showed this on one of the first slides. And so we take the score for each of the four categories or each category, we multiply it by the corresponding weight, and we add those up to get your final score between zero and 100 points. For year three, the quality category accounts for 45% of your final score, the cost category for 15%, improvement activities and promoting interoperability have not changed and they make up 15% and 25% of your final score respectively.

Next slide... Alright. So we'll talk about the quality category in a little bit more detail. Not a whole lot of changes for year three. We have lowered the overall category weight to 45. You're still generally expected to report on six quality measures, and one of those needs to be an outcome measure. Or if an outcome measure is not available, another high priority measure. You can also report on a specialty specific set of measures. And for our program year 2019, we have a total of 257 MIPS CQMS that are available. So we remove some measures that were either duplicative or topped out, and we added a few measures including some patient reported outcome measures.

Next slide. We continue to have bonus points that are available for quality, and we have two kinds of bonus points. One is for additional high priority measures that are reported. You can get either two bonus points if those are outcome are high for patient experience measures. Or one bonus point for other types of high priority measures. We also have bonus points for end-to-end electronic reporting of measures, and this is getting data from your certified EHR system to us without any manual interruption. We also have moved the bonus that we had for small practices, which used to be at the final score level. We've moved it into the quality category. And so now, small practices that have 15 or fewer commissions and report at least one quality measure will get six points added to their quality category score. We've also added a high priority type to reflect opioid-related measures in recognition of our efforts to address the opioid crisis.

Next slide. For the cost category, we have raised the weight from 10-15% for year three. We continue to have the two measures we had in year two, which were the Medicare spending per beneficiary measure and the total per capita cost measure. But for year three, we've added eight episode-based measures that might apply to commissions and groups if they are attributed a sufficient number of patients for those measures. And as I mentioned before, the cost category requires no additional data submission on the part of the commission.

Next slide. In promoting interoperability category has undergone a lot of changes for year three. First, we renamed it from the Advancing Care Information Category to Promoting Interoperability to align with some of our other programs and also to better reflect the intent of this category, which is to make information available better... More available to patients and to providers. So it continues to make a 25% of your final score, but we've eliminated the previous scoring system which had a base set of measures instead of performance measures and a bonus score. And now, we just have performance-based scoring on a set of required measures.

Next slide. So there's one set of objectives and measures that you are required to use, the 2015 edition of certified EHR technology for year three. And there are four objectives, which I'll show on the next slide. And then a number of measures under each of those objectives.

Next slide. Alright. This shows the measures and objectives for the revamped promoting interoperability category. So you see we have objectives for E-prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange. Underneath each of these, there's a set of measures that are required to be reported. The exceptions to this is under e-prescribing. There are two optional measures for which you can get bonus points and both of these are related to opioid treatment and prescribing. But otherwise, you do need to submit information for each of the other measures and then, you will be scored on each measure that you submit up to the maximum points that are shown on the right-hand side of this slide. Then these will be added up and compared to a total possible score of 100 points to get your percent for the category, and then we will apply the 25% weight to those points.

Next slide. One other thing that you have to do in this category is you have to attest to a number of things related to security, risk assessment, and information walking. And so, you do need to attest yes to each of these attestation questions before you can get any points in this category. And this again is to further our efforts to promote interoperability and data sharing from these certified EHR systems. So I think that's my last slide. I will now turn it over to Angela to talk about improvement activities.

>>FOSTER: Thanks David. Hello everyone, I'm Angela Foster. I'm the program lead for improvement activities here at CMS. I will be going over the improvement activities performance category for email. When MIPS started improvement activities with a new performance category, as many of you are probably aware, it was intended to include activities that MIPS eligible commission, organizations and relevant stakeholders have identified as improving clinical practice or care delivery. The end goal is improved outcome. The IA inventory includes over 100 activities divided into nine sub-categories. We worked hard to keep this program flexible by allowing you to choose activities that are most meaningful to your practice. You don't have to select activities from each of the nine sub-categories or from a certain number of sub-categories.

Next slide, please. Improvement activities is worth 15% of your total MIPS score in 2019. You may simply attest to having completed an activity. For performance year 2019, we have not changed the activity weight of the activities. A medium is still worth 10 points and a high-rated activity is still worth 20 points. We have special scoring considerations for small practices, non-patient facing clinicians, and/or clinicians located in rural areas or HPSAs.

Next slide please. Please when you have a chance familiarize yourself with the improvement activities inventory by reviewing it in the Resource Library on the QPP website. You will also, find our validation criteria there, the validation criteria outline, what documentation you would need to retain for each activity listed in the inventory.

It also helps to provide a framework for how the activity should be performed. When we get a lot of questions through the service that are about particular improvement activities, we often steer folks to the validation criteria. If you get a chance to review that and also carefully read the activity description, you'll find that you'll have the information that you need to know how to perform the activity and also to know what documentation you should retain and for how long.

Next slide please. Here is the breakdown of the improvement activities requirements for clinicians to qualify for special status and for those who do not. So for instance, if you are a missed eligible clinicians in a practice with 15 or more clinicians, you would need to perform either two high weighted activities, one high and two medium or four medium weighted activities. If you qualify for special status, the activity weights are actually doubled for you. You would need to perform either one high weighted activity or two medium weighted activity.

Next slide please. Here you can see the different data submission types that are permissible for the improvement activities performance category. David went over these earlier in a little more detail, but just as a reminder, these will include direct login and upload and login and attest. Again, as I mentioned before, we've tried to keep things simple and as flexible as possible for eligible, MIPS eligible clinicians.

Next slide please. Calculating your improvement activity score is pretty simple. You will take the total number of points earned for your completed activities and divide them by the total max number of points allowed in the performance category. For improvement activities, the total max points allowed is 40. Take your results and multiply that by 100, this will give you your improvement activities performance category score.

Next slide please. Here you can take a look at some examples that we've provided of what your score could look like based on different circumstances. It's just basically giving you a couple of different scenarios based on different improvement activities that you could have reported if you just report one, if you just report two, this is how your score would differ in those situations.

Next slide please. A couple of things worth noting about the improvement activities category before I close. Participation in the CMS study on factors associated with reporting and quality measures can earn you improvement activities credit. Here, we give a little information on what those study requirements are, what participants need to do to participate. Also we have... We hold an annual call for improvement activities, and this is a process for allowing clinicians and organizations to identify and submit improvement activities or modification or you can also submit modifications to our current improvement activities for consideration.

The call is currently open, it opened on February 1st of this year, and it will close on July 1st, 2019. You can find all the information on the criteria we used for selection as well as our submission form and fact sheet on the call for improvement activities and the Resource Library on the QPP website. I will now turn the presentation back over to Molly MacHarris and I thank you all for listening. Next slide please.

>>MACHARRIS: Thank you Angela, and thank you everyone for still bearing with us. Just one more slide, I want to touch on or well actually start just a few more slides I want to touch on. So now everyone should be... So now everyone should understand the eligibility basics of the Quality Payment Program, particularly the MIPS track. So whether or not you're eligible or whether or not you're excluded. David went over the details of how you can participate in the program and then the three performance categories, quality, cost, and promoting interoperability. And Angela just went over the improvement activities, performance category. So now, I just want to briefly touch on what the end results of all of that is.

So as I mentioned previously, what we do under the MIPS program is we assess your performance on those four categories. As David and Angela talked about each of those four performance categories has a weight associated with it. And that weight impacts how much your performance on a given category will contribute to your final score. And again, as I've mentioned a couple of times here today, where we ideally want everyone's final score at in the third year of the program, so for your performance in calendar year 19 is 30 points or greater.

So let me talk you through the right-hand chart on this slide. So looking at the green row first and then moving our way up. So again, if your final score is at 30 points, that means that you are receiving a neutral payment adjustment. That means you would not see any update to your payments in 2021. There would really be no impact. But if your final score is anywhere about 30 points that means that you would potentially be getting more money on your claims beginning in 2021.

So if your final score is anywhere between above 30 points up to 75 points, you would be getting a MIPS payment adjustment. By law, the MIPS payment adjustment in year three, can be up to 7% subject to a scaling factor to ensure budget neutrality. Budget neutrality means that the total amount of money that we would be taking away from clinicians, who have a negative adjustment that has to neutral out the total amount of money that we would be able to distribute to clinicians on the positive end.

So, again, if your final score is anywhere about 30 points, you would be getting a MIPS payment adjustment. If, however, your final score is at or above 75 points, not only would you be getting the regular MIPS adjustment which is subject to those budget neutrality requirements I just talked about. But Congress have allocated for us in the first six years of the program an additional bucket of $500 million that we can allocate annually for exceptional performers. So you are considered to be an exceptional performer if in the third year of the program, your final score is at or above 75 points.

So what that means is that you would be getting an additional bonus that you would potentially be getting an even higher payment adjustment. So that's where we ideally would like everyone to be at. But let me go ahead and talk through the negative adjustment side. So, again, let's talk through those bottom dark greenish bluish rows. So looking at the bottom, bottom row first. So, by law, if your final score is in the lowest quartile, we have to give you the maximum negative adjustment. So that means if that if your final score is 7.5 points or lower, you, by law, have to receive the maxim negative adjustment of -7% on your claims in 2021.

If your final score is anywhere above seven and a half points up to right below 30 points, you would still be getting a negative adjustment but it would be somewhere on a linear sliding scale to ensure budget neutrality. So, again, when you think about budget neutrality, the total amount of money that we can distribute on the positive end have to equate to the total amount of money we anticipate we would recoup on the negative end.

I hope that makes sense. Again, if there's time at the end to take questions, happy to talk through this in more detail. There's just a few more slides I want to touch on before I turn it back over to Steve. So let me just briefly talk through some of our help and support. If we can go ahead and move to the next slide. So as I've mentioned, as well as my colleagues, David and Angela, have mentioned a number of times here today, we have a lot of resources available to you. So one of the best resources is the website. We have a lot of information on there, we have a lot of tools that you can use to determine if you're eligible, what measures and activities would apply to you.

We also have our service centers or our help desk. They can talk you through really any questions that you have. So if you have questions, feel free to reach out there. We also have a number of resources available for different types of practices. So if you are part of a small practice and we define small practices as 15 or fewer clinicians or if you are in a rural area, or medically underserved area, we have free dedicated technical assistance. You can reach out to these people as the information on the slide here reflects and our free technical assistance includes for people can actually come to your office and help work with you on implementing the Quality Payment Program.

We also have our larger QIN-QIOs who are available, again, who can really help with some of that boots on the ground resource that we know many of you all may need. We also, of course, have a transforming clinical practice initiative which some of the goals of that initiative is really to, again, transform practices and really try to learn from some of the best practices that organizations across the country have been able to implement as they have been making the transition to value-based care and moving towards participation in an APM.

And then if we just jump to the next slide, just the last piece I want to touch on briefly. I got as our website, We have a number of Quick Start resources that are available there for our 2019 year. We're adding more information there all the time. Every couple of weeks, we're adding more information. So, again, I highly encourage you to bookmark that site so you can come back to it. So that's everything that we have from the CMS perspective. So at this point, I'm going to go ahead and turn it over to Steve to move us forward. Steve.

>>SINGER: Thank you so much, Molly. Really appreciate it. So we're now going to talk about your questions that you've submitted and we'll go pretty quickly since we have a limited amount of time left. So the first question that we have is, "How can my accredited CME program support my organization with regards to QPP and MIPS?"

>>McMAHON: This is Graham again. First of all, thanks for our colleagues from CMS. I think the background information that largely focused on the needs of health care practitioners is essential for the CME providers to understand as they begin to implement improving activity that are helpful here both in terms of needing to communicate the basics of the QPP Program to their community. First of all, that's an educational objective of itself but then to facilitate their engagements in accredited improvement activities.

I think the second point is, make sure you are aware that this is an open process that is content naive so you can select the right target that's relevant for your audience. Whether you're a big society, whether you're an educational company, whether you're a hospital or health system, you can use the system to meet the diverse needs of your community and ones and two groups or as groups of tens of thousands of physicians.

Number three, you can have way very substantial payment withholding from CMS on the basis of lack of participation and things like improvement activities which you're probably already doing anyway. So a matter of orienting your quality assurance and quality improvement programming can help your organization and clinicians, who are your members, avoid substantial payment penalties to their Medicare payments.

You already heard Angela describe that if clinicians want to maximize the 15 points that they can get for improvement activities, they need to complete four medium activities in a year through your system. And that means one activity per quarter of these accredited improvement activities will maximize your contribution to the clinician's ability to get points and that over half a million, probably over 700,000. Physicians nationally need these points. So you need to... You can really help them a lot by leveraging leadership. And finally, helping your community solve the test, that they have completed improving activities with you and by listing those improvements in our data systems that will help you orient your clinician community to those opportunities.

>>SINGER: Thanks, Graham. Another question to give more specific about addressing MIPS with CME. "Do I need permission to start providing accredited continuing education activities as MIPS improvement activities?"

>>McMAHON: No. That's an easy one. Essentially, if you're on a credited provider, there's no fee, no charge. As long as you are comfortable with and familiar with the process, and know how to do this, then you can do these improvement activities as you're already doing but then give your community of completers instructions on how to do a test that they have done so, that they meet the expectations of MIPS and the data documentation, if you already retained, because of your accreditation requirements are sufficient for meeting CMS's requirements.

>>SINGER: Thank you. So another question to follow up about MIPS improvement activities that are CME, what kinds of educational outcomes would count for accredited continued education MIPS improvement activities and do those outcomes have to be quantitative?

>>McMAHON: Well, they definitely don't have to be quantitative. Although many activities could be around performance objectives that are quantitative; the fraction of patients who stopped smoking or the number of clinicians who engaged in more effective hand washing. But they could be absolutely qualitative in that they can be self-reports of clinicians of what they have seen in their practice as a result of an improvement that was made. They can be based on observations. I've seen the following occur or the following technology has been applied, or extra hand sanitizers have been installed. Those types of things are perfectly reasonable to describe as the basis of an outcome variable for an improvement activity.

And I would just go back to the list of requirements and for ACCME accredited MIPS improvement activities that meet these expectations. And, again, remind you that you can use CME for these. You can issue to CME credits to these activities, MOC credits in many cases and help your clinicians maximize their points for MIPS.

>>SINGER: Thanks, Graham. So, really, if I can contextualize what you just shared, that if you look between the elements of improvement activity here, if you look between one, two, three and four, we see the common framework of accredited continuing education that looks at a problem in practice, designs interventions to address a change or improvement and then collect data and analysis to look at what has changed as a result of the intervention. To continue with another question, if we look at number five here, these expectations say that the accredited program must define meaningful clinician participation in their activity. Can you help to explain what that means by meaningful participation?

>>McMAHON: So it's already captured in the accreditation requirements of being able to validate whose completed your educational programs. So the same is true from improvement activities. You need to know who is there, what they did and it can be characterized by the group or the individual for it to count.

>>SINGER: Thank you. And it's interesting that that is the same expectation that we have and see in many of the maintenance certification requirements with regards to the provider's ability to define how their learners will participate in and complete continuing education activity. I think, Graham, you've answered the next question. We'll go to the next slide. "So can I provide accredited CME MIPS improvement activities for individuals and/or groups?"

>>McMAHON: For sure.

>>SINGER: For sure the answer is yes. Okay.

>>McMAHON: The important thing here is to realize that this process is designed to be maximally flexible to meet the individual relevant needs of a group or a clinician. So whether you define a process for your organization that says every clinician can come up with their own improvement focus and tell us what they did and that it was successful or what they learned from the process, or what the outcome was. Or we define a process for our entire community of members or employed clinicians, for example, around the key objective for the organization. Either of those processes can use... Those approaches can use this process to meet the expectations on improvement activities and the accredited team.

>>SINGER: Great. And the last question is, we're of course at the end of the hour, "What documentation is required to evidence learner participation and accredited continuing education for MIPS?" You already had said a moment ago that in terms of our accreditation process, there's nothing additional. Perhaps, David, if you're still on the phone, if you could address from the standpoint that when providers or organization submit data via the means that you described about improvement activities. Can you talk about the format or the form that that information takes that they're submitting?

>>NILASENA: Yeah, I think Angela is still on it. She wants to answer that.

>>FOSTER: So, yeah, the improvement activities category is really simple. It's just attesting, yes, that you completed whatever your selected activity is and you can do that directly on the QPP website. You just go in, select your activities, upload and send it to us. It's super simple. I've gotten feedback from clinicians and different organizations, different groups I've done site visits, and they're all loving the simplicity of the program. So I hope that helps.

>>SINGER: Yeah, thank you. So if we'll take a look at the... Or you want to see if we have some chatted questions. Okay, so one question was, "How can we incorporate CME for MIPS." I think we talked about that. We are in a medical education company that offers quality improvement activities specifically to oncology specialists. Are there MIPS quality measures, specifically for oncology specific to oncology, measuring how well oncologists are implementing guidelines concordant with expectations. Maybe that's a...

>>McMAHON: So I'll give it a shot. And then, Angela you might have an opinion about that. But essentially on the MIPS system, there are specific outcome variables and processes that are approved by CMS and if those meet your expectations, then you may want to just use those articulated patterns for doing improvement activities that are already listed on the improvement activities website. If however they are not there and you want to use the open frame process of accredited improvement activities, you can choose an outcome variable and a process that's right for you, as long as it meets the core requirements of the improvement activity, as outlined on the website.

>>NILASENA: Yeah, I think that's basically right. So on our CPP website, there's a nice look-up tool for each of the categories where you can look up particular quality measures or improvement activities or measures related to promoting interoperability. You could type in a keyword like Oncology or cancer and it would bring up any matching measures or activities related to that. I can tell you for sure that in the quality category there are measures related to oncology. I think for the improvement activities, there are a number of them that are broad enough that they certainly could encompass oncology.

>>SINGER: Thank you, David. So just to wrap up today, I wanted to share with you that our ACCME website has resources, we have a special CME for MIPS page that collects resources, such as a tool, a handout that you can use to help identify those activities that you may already be doing that meet these MIPS expectations. As well we have some frequently asked questions that we will update now given this great amount of information that we got today. As well, I think it's clear that as a CME community, there's a lot that we can do together to help inform how you facilitate this process for your learners.

We will be having sessions at the ACCME 2019 meeting coming up at the end of April, and you could look to us to continue to get information and resources about bringing this even further into your context as continuing education providers. So your next steps really, as a continuing education leaders, are to identify continuing education activities you are already doing. It could be MIPS improvement activities because they are addressing quality and performance improvement.

You can talk to organizational leaders in the way that Graham described about the educational gaps that exist in your institution around QPP and MIPS and help to serve that broader educational need. You can register activities and QPP Graham described at the very beginning of the webinar that there is an easy alignment between MOC expectations, MIPS and as well as other regulatory expectations like the Joint Commissions OPPE.

And lastly, we really want to hear from you, about your experiences and successes in bringing greater value to your learners and your institutions around providing MIPS improvement activities. So with that, the very next slide, if you need further help or want to communicate with us, you can of course reach the CMS folks, and the quality payment program at their website, And as always, you can contact ACCME at and visit our website for additional resources. Thank you again to our CMS colleagues today for joining us on this webinar, thanks to Graham and thanks to all of you hope you have a great afternoon.