Are you an anesthesia provider participating in the Merit-Based Incentive Payment System (MIPS)? Let us tell you how the SurveyVitals solution might help you fulfill certain reporting requirements.
The Merit Incentive Payment System (MIPS) is one of two tracks in the QPP, the quality payment incentive program implemented by CMS. A small percentage of clinicians will qualify to participate in the Alternative Payment Models (APM) track, but most anesthesiologists will fall under the MIPS track.
You will receive a performance-based adjustment to your Medicare fee schedule in 2022 based on your MIPS performance in 2020. The amount of the adjustment, either positive, negative, or neutral, is based on an eligible clinician or group’s Composite Performance Score (CPS). The CPS is calculated using data across four categories of measurement.
If you bill Medicare Part B more than $90,000 in allowed charges per year and provide over 200 covered professional services under the Physician Fee Schedule for more than 200 unique Medicare patients a year, then you are part of the QPP. If you do not meet all three criteria, you could be exempt from participating in the program in 2020 under the the low-volume threshold exemption. Clinicians who meet the low-volume threshold may still opt in to MIPS if they meet at least one criterion.
To determine if you are required to participate in MIPS, CMS has provided a resource to check your status by entering your NPI into an eligibility “calculator.”
Anesthesiologists have the option to report as an individual, within a group, or within a virtual group.
|Individual||Single NPI tied to a single Tax Identification Number (TIN)|
|Group||Single TIN with two or more eligible clinicians, including at least one MIPS-eligible clinician, as identified by their National Provider Identifiers (NPIs), who have reassigned their Medicare billing rights to the TIN|
|Virtual Group||Combination of two or more TINs assigned to one or more solo practitioners or one or more groups consisting of ten or fewer eligible clinicians|
Reporting mechanisms vary based on reporting type and measure category. You can find more information on reporting mechanisms here.
Anesthesia providers and groups can select measures from the list of CMS-approved MIPS measures at the QPP website. Alternatively, they may select to report on Quality performance using specialized measures developed by a Qualified Clinical Data Registry (QCDR) of their choosing. QCDR measures must be approved each year by CMS.
Anesthesiologists are required to report on six measures of their choosing for the quality category. One of those measures must be an outcome measure.
SurveyVitals is equipped to help anesthesia clients utilizing a QCDR to meet an outcome measure (AQI 48 – Patient-Reported Experience with Anesthesia) in the Quality category. You must sign a disclaimer in order to report your patient experience data to a QCDR. View the reporting checklist, quick facts, and important deadlines here.
Anesthesia providers are required to participate in a combination of IA measures totaling 40 points. “High-weighted” activities are worth 20 points, while “medium-weighted” activities are valued at ten points. Your SurveyVitals solution can help you satisfy measures in the IA category. Download our “Road-Map to Improvement Activities” or contact us at email@example.com to learn more.
In order for a group or virtual group to attest to an improvement activity, at least 50% of the clinicians in the group or virtual group must perform the same activity during any continuous 90-day period in the performance year.
Reporting requirements for Improvement Activities are reduced for non-patient facing clinicians, which are defined as either:
Those considered non-patient facing must participate in one high-weighted activity or two medium-weighted activities to satisfy the Improvement Activities category (for a total of 20 points rather than 40).
Always remember to check the eligibility calculator on the QPP website to confirm you are considered non-patient facing.
The Promoting Interoperability category places an emphasis on interoperability and patient engagement with certified EHR technology. Eligible clinicians must report on certain measures from four ‘objectives,’ or claims exclusions if applicable. Scoring is performance-based at the individual measure level, for a total of up to 100 points. In 2020, organizations must use the 2015 Edition CEHRT.
The score for the Cost category is calculated using administrative claims data. No data submission is required.
SurveyVitals can help you meet one Quality measure and fulfill the entire Improvement Activities category. Reference the table below to see which measures we can help you meet.
|MIPS Category||Measures We Support||More Information|
|Quality||AQI 48 (Outcome)||Anesthesia QCDR Reporting|
||Improvement Activities Roadmap|
Want to learn how SurveyVitals can help you prepare for MIPS? Email us at firstname.lastname@example.org. You can also send us a message using the blue chat icon below to speak to a member of our support team.
*Note: Information and program details are based solely upon SurveyVitals’ experience with MACRA and our interpretation of CMS rule-making and policy statements. The information presented does not reflect the views or policies of CMS or any other governmental agency and is not to be construed as practice management advice.
blake June 3rd, 2018 Categories: Anesthesia, MIPS InformationTags: anesthesia, anesthesiologist, CRNA, improvement activities, macra, MIPS, QPP, quality category, quality payment program
The redesigned MOCA 2.0 (Maintenance of Certification in Anesthesiology) allows anesthesia diplomates to complete a variety of new activities to meet the Part 4 Quality Improvement requirement. Diplomates are required to earn a minimum of 50 points during their ten-year MOCA 2.0 cycle by choosing and completing quality improvement activities most relevant to their practice.Where does SurveyVitals come in?
You may be able to use the SurveyVitals solution to fulfill the requirement by completing an improvement plan based on A) 360 professional reviews, or B) patient experience of care surveys. The point value for this activity is 1 point per hour spent on the activity, for a total of up to 25 points.
SurveyVitals’ Anesthesia 360° solution offers surveys for patients, practitioners, administrators, surgeons, and peers to give you a comprehensive look at patient and professional satisfaction.
Don’t know where to start? Your survey dashboard provides a detailed visual of areas scoring the lowest and receiving the most low-score alerts, allowing for quick identification of improvement opportunities. SurveyVitals’ robust reporting options allow you to easily track and measure improvement in these areas over time based on near real-time patient feedback.How can I attest to meeting this requirement?
Diplomates must attest to the activity on the American Board of Anesthesiology (ABA) website using the ABA-approved template found here. Your SurveyVitals data can be used to summarize both the Data Summary and the Change in Practice.
More information about the MOCA 2.0 Part 4 requirement can be found on the ABA website.
blake June 1st, 2018 Categories: Anesthesia, Product FeaturesTags: anesthesia, anesthesiologist, CRNA, diplomates, Improvement, maintenance of certification anesthesia, MOCA, Quality
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Provider Spotlight: Tina Eide, MD, Matrix Anesthesia
Tina Eide, a board certified anesthesiologist from Matrix Anesthesia, was one of the winners of our recent Patient Experience Week giveaway. We asked Tina about the best practices she follows to provide exceptional patient care, and we’re excited to share her responses.
Tina studied medicine at the University of Washington and trained at Virginia Mason Medical Center. Her primary areas of work interest include regional anesthesia, neuroanesthesia, lifestyle/behavior, and anti-aging medicine.
What best practices do you and the staff you work with follow that you attribute to your positive scores?
Tina Eide: [The] Overtake Hospital pre-operative setting includes private rooms for each patient, so interviews can be conducted with a closed door, and a quiet environment. This is instrumental in developing patient trust, explaining anesthetic choices, and creating a safe space for patients to voice anxieties or fears. Also, the pre-op nurses are excellent and gather information ahead of the anesthesiologist meeting the patient, so we don’t have to be entirely reiterative.
I always try to ask several specific questions about a patient. By knowing a few personal details, I can often begin talking about a familiar topic that helps put the patient at ease. I’ve even gotten three patients to sing for me recently!
Finally, I always offer my first name after I’ve introduced myself as Doctor Eide. I give my patient the choice of which to call me, and most prefer calling me Dr. Tina or just Tina. I am able to communicate through this that I am a professional but I am also a human.
What is one example of how you improved your relationship with your patients and/or the care you provide?
Tina Eide: When I first began, I was hesitant to explain all the risks that are inherent to anesthesia with patients. I felt this information might burden them or raise their anxiety prior to surgery. As I grew as a doctor and learned from my patients, I realized that patients are entitled to know the specifics of the care they will receive while under anesthesia. Some patients will decline a total explanation, and this is just fine. Other patients want to know each event that will occur and the possible up and downsides.
I learned that if I was upfront and explicit about the risk discussion, patients were extremely appreciative and their trust in me grew as well.
How do you best use your SurveyVitals data for your own personal improvement?
Tina Eide: I look for the specific comments that patients make about their experiences. Often we only hear general feedback like “great job” but when people relay a certain moment that touched them, or a particular action I did that helped them feel at ease, I am able to repeat that going forward.
I also accept any critical feedback with an open mind and heart. As a doctor, I hold myself to an exceptionally high standard to ‘do no harm’ which can sometimes translate in my mind as ‘make no mistakes.’ Clearly, as a human being, I have to accept that I will make a mistake now and again. If I can hear the critical feedback well enough to learn from it, however, I see it as a growth opportunity rather than something negative.
blake September 16th, 2019 Categories: Anesthesia, Best Practices, Client Spotlight, featured, Patient ExperienceTags: anesthesia, anesthesiologist, Best Practice, Improvement, Our Clients, patient comments, patient experience, Patient feedback, Patient Satisfaction