I'd like to welcome all of you to our next installment of our virtual forum web-based lecture series. This is a series of presentations by experts in our sub-specialty from across the country. The original objectives were to focus on the SPRMS learning objectives, however, we have expanded the content area to also include practice topics in order to more fully engage all members. In addition to letting you learn from the experts, you are also given the opportunity to interact with our experts in our field in real time. This presentation will then be captured and made available for view at any time on the OGG website. Upon completion of this program, you will be given the opportunity to provide some feedback which we value greatly for future planning. For this evening's presentation, it is my pleasure to introduce Dr. Robert Flora. He is currently the Director of Medical Education and is the ACGME DIO at Providence Park Hospital in Michigan. In addition to this, he is also a professor for the Department of OB-GYN at Michigan State University College. We are also joined by Dr. Sage Clayton, who is a partner in the Urogynecology Associates of Philadelphia, part of the Mainline Healthcare Group, and she is also a clinical professor at Lacknell Medical Center. So their presentation today, they are giving a joint presentation, is going to be on Show Me the Quality. There have been a lot of changes in the healthcare field with regards to quality reporting and this webinar is designed to inform the OGG's membership about the recent changes on the quality payment program, what they need for our practice, and what obligations we're going to have for this moving forward. So thank you, Drs. Flora and Clayton, and with that, we'll get our program started. Okay. Thanks for the introduction. I want to thank everyone for joining us tonight on the webinar. I'm Sage Clayton and myself and Bob Flora will be going through the new quality program taking effect this coming January. Before we start, I'd like to acknowledge the quality committee members who worked so hard on this webinar, Sarah Boyles, Mark Preston, Melanie Santos, and Daden Morgan, as well as our OGG's staff, Nui, Will, and Adrian, and finally, Jill Rathbun, who is one of our consultants to OGG's with the Galileo Group, and without whom, much of us would be lost. Jill is on the webinar and she'll be assisting with answering questions later. Tonight, we're going to review the new quality program proposed for 2017. We'll discuss who will be affected, which is nearly all of us. We'll talk about how the program works and how reimbursement will be affected, and though not necessarily in that order. Then we'll pause to give you a chance to write some questions, and then Bob will discuss what we can do to prepare. Last year, MACRA was signed into law replacing the Sustainable Growth Rate, or SGR, as a model for Medicare physician reimbursement. For 2017, CMS has renamed MACRA the Quality Payment Program. The Quality Payment Program, which is formally known as MACRA, combines the current programs of PQRS, Electronic Health Record Meaningful Use, and Value-Based Modifier into one reporting program, which will determine Medicare payments to participating providers in a budget-neutral fashion. The law, or rule, goes into effect for quality reporting January 1, 2017, and will affect Medicare payments received by providers in 2019, so there's that typical two-year delay we're used to. Now, this proposed Quality Payment Program is still under review by CMS, and OGS and other medical societies submitted comments back in June with suggestions to CMS to try to make the program more valuable to OGS members. The final rule, or law, won't be available until November of this year, but much of the content that's currently in it will remain unchanged. Now, since reporting requirements are currently set to start January 1 of next year, it's really important to start preparing as soon as possible. This is a timeline of how the new program will be rolled out. Currently, most of us are receiving a baseline fee with a bonus or penalty payment based on our quality reporting through PQRS, Electronic Health Record Meaningful Use, and or Value-Based Modifier quality reporting. The base fee will be continued through the first year of the Quality Payment Program with a payment adjustment based on individual quality scores, and we'll talk about how those scores will be calculated in a minute. Now, this baseline fee will be phased out for 2020, and your payments will then be predicated on your overall quality score. So we will be discussing how the score is determined as we move forward through tonight's talk. But before we do, let's review what we're all doing now. So our existing quality programs started in 2008, and these include PQRS, Value-Based Modifier, which was started as a part of the Accountable Care Act, and Meaningful Use of Electronic Medical Record, which started as part of the 2008 stimulus package. Currently, there is a baseline Medicare fee called the SGR, which is updated yearly. And our quality reporting through one of these three programs affected the payments we received from Medicare, either positively or negatively, with a two-year payment delay. So our reporting, our payments lagged two years behind, or our reporting affected our payments two years, the following two years. These current programs are in effect for reporting now, and there's a two-year delay for payment adjustment. So what you reported through these programs in 2014, 15, and this year will affect your Medicare payments for 2017 through 19, respectively. These current programs are getting combined into one program under the Quality Payment Program, or QPP, for reporting next year. So the new QPP has many components, which you are already doing in your practices. And these are going to continue pretty much as is, with just slight modifications. So this should give you some comfort as we transition to the new system. Okay, let's talk about the Quality Payment Program, formerly known as MACRA. Under the QPP, physicians choose one of two payment options or tracks. So providers can either choose to report under MIPS, which stands for Merit-Based Incentive Payment System, or participate in an Advanced Alternative Payment Model. The vast majority of providers, however, will not qualify for an Advanced Alternative Payment Model under the new system, even if you're already participating in an Advanced Payment Model currently, and will be required to report through MIPS. Now physicians are allowed to switch from year to year if they qualify to do so. But as most of us will not qualify for an Advanced Alternative Payment Model, tonight we are going to focus on reporting through MIPS. Okay, so MIPS, it stands for Merit-Based Incentive Payment System, and that payment system part is really the most important part of the MIPS. In other words, this is the new way Medicare pays providers. The MIPS program generates a composite score index, and the score is based on your PQS reporting, or now named quality, your risk-adjusted resource use, which is similar to the value-based modifier, your electronic health record use, which they've renamed Advancing Care Information, and then they've added a new category called Clinical Practice Improvement Activities. And these look at patients' access to care and patients' participation in their plan of care. Each of these categories account for a percent of your total MIPS score, and the score will in turn determine your reimbursement. So, for example, in year one, 2017, quality reporting will account for 50% of the final score. Cost, also known as resource use, will account for 10%. Clinical Practice Improvement Activities will account for 15%, and Advancing Care Information, formerly known as Electronic Health Record Meaningful Use, will account for 25%. And these proportions will change as the program matures. Now, the scores in each category have their own range of possible points, which are weighted, and then they're combined, so before the percentages, they are combined to give you a final score. And as the program matures over the next three years, the relative weights of each activity will change, resulting in quality reporting eventually having the same weight as resource use by year three. So, who will be affected by MIPS, or the Merit-Based Incentive Payment System? Well, most Medicare providers will fall under MIPS unless it is their first year that they are participating in Medicare Part B, so those who are in a new practice or those in a new tax identification number, if they qualify for an advanced alternative payment model under QPP, or three, if their Medicare billing charges are less than or equal to $10,000 in the reporting year, and they care for less than 101 Medicare patients in the reporting year. This is Medicare billing charges for reporting year to affect Medicare payments in the payment year, so reporting in 2017 for payments in 2019, et cetera. In the first two years, physicians, physician's assistants, nurse practitioners, CRNAs, and clinical nurse specialists will be affected by MIPS. Other clinicians may be included as the program matures. And providers can either participate as a group, as long as all providers in the group share the same tax identification number, or as an individual. For group reporters, the Medicare payments will be based on the overall group score, independent of the provider's individual performance. Providers eligible for MIPS reporting, either as a group or as an individual, are referred to by CMS as eligible clinicians, or ECs. So if you go to the CMS website and you're trying to read on these programs, which I encourage you to do, you'll see ECs sometimes, and that just means eligible clinicians. It can refer to either you alone, or your group. Each EC will choose the same MIPS identifier for all four of the MIPS categories. So if you're reporting as an individual, your identifier will be a combination of your NPI number and your tax ID number. If you're reporting as a group, it will just be your tax ID number. And a group can be two or more eligible clinicians. So it just takes two to form a group under MIPS. Okay, so now that we know who is eligible to report under MIPS, let's transition and discuss how MIPS works, and the components of the composite performance score. There are four categories which are weighted on a 100-point scale. These are quality, resource use, clinical practice improvement activities, and advancing care information. Now most of these are already familiar to us. Our performance in each category will be weighted for a combined score, which will determine our reimbursement for Medicare services. The first MIPS category is quality, and this is similar to the current PQRS program we are already using. Now with the new quality program, physicians can still choose which measures to report. But under MIPS, we only need to report on six measures instead of our current nine, and there is no domain requirement. Also, you only need to select one cross-cutting measure and one outcome measure or other high-priority measure if outcome is unavailable. Measures can still be selected based on which are most relevant to the group's practice, such as our AUGS measures. So the key changes from our current PQRS are we have fewer required measures with no domain requirement, and there is now an emphasis on outcome measures. The next category that goes into your score is called resource use, and this replaces the current value modifier program. It ranks resource use for similar care episodes and conditions across practices and compares clinicians or clinician groups to each other. Knowing that not all patients are created equal, CMS does use risk adjustment in its cost-of-care attribution, and this is based on ICD-10 codes. Now not all practices are currently using value-based modifier, so this may be new to some of you. To make it easier, remember CMS automatically calculates resource use based on claims, so there are no reporting requirements for clinicians. They are adding at least 40 episode-specific resource use measures to address specialty concerns, and providers are assessed under the available resource use measures, which apply to the clinician or group. So the key for those currently participating in value modifier program are there are now 40-plus episode-specific measures to address specialty concerns. Just briefly, what CMS is looking at in terms of resource use is the total per capita cost across Medicare beneficiaries, and this really applies mostly to primary care. They're also looking at risk-adjusted Medicare spending per beneficiary three days prior to inpatient admission through 30 days after discharge, so this might affect us as OGS members. And they're also looking at a new condition-treatment-based measure, these 40-plus measures they've created, they're also called group episode measures. And these really were designed for specialists, though not many of them apply to OGS members yet. So a clinician must have at least 20 cases attributed for a particular episode group to have an episode group measure as part of the clinician's resource use performance score. Now I know this is a lot to absorb, but don't worry. More details are available on the CMS website, and we can answer more questions about this near the time of the annual meeting as well. Now the next part of the MIPS score is clinical practice improvement activities, and this is new for 2017. And some examples of this would include patient care coordination, shared decision-making, safety checklists, extended office hours, things like that. CMS has a list of 90 proposed clinical practice improvement activities, with about 20 of which are applicable to OGS members. Members must select at least one clinical practice improvement activity, but will get additional credit towards their composite score if they do more activities. Each activity is rated from low to high, and you'll need about three high-rated activities to get full credit in this category. Now people who are participating in patient-centered medical home get full credit in this category regardless, and those who are in an advanced payment model and are participating get half credit towards their CPIA score, even if they're not in a qualified advanced payment, advanced alternative payment model under the new QPP. Now the final category that goes into your score is called advancing care information, which is similar to the current electronic health record meaningful use. The scoring is based on key measures of health IT, interoperability, and information exchange. And these are designed to promote care coordination with the thought being it will lead to better patient outcomes. CMS has proposed six objectives, and they're measures that go into a base score, and three objectives and measures that will go into a performance score, some of which are simple yes, no, did you do it, didn't you do it, and some are numerator, denominator-type measures. So for example, for electronic prescribing, if you look in the box, it says numerator, denominator. So the numerator here would be yes, because you prescribed electronically, and the denominator would be the total number of Medicare patients who received a prescription. Your overall score in this category is made up of a base score plus a performance score for a maximum of 100 points. And then that 100 points, if you get 100 points, that goes into calculating your total composite score. The six objectives for the base score are did you protect patient health care information, did you prescribe electronically, do patients have electronic access, is there coordination of care through patient engagement, is there health information exchange, and then is there participation in public health and clinical data registry reporting. For the performance score portion, it will be composed of patient electronic access, coordination of care through patient engagement, and health information exchange. And remember, the performance score combines with the base score to generate the total score in this category. So what does this all mean to you? Well, remember, MIPS stands for Merit-Based Incentive Payment System, so it uses the calculated composite performance score in the four categories to determine your reimbursement for Medicare services. This payment system is budget neutral and bell curved. The bell curve is generated by your or your group's composite performance score, so your bonus or penalty is based on your composite score. The top 25% of the bell curve will be paid more, and that money that they receive will come out of the payment to the bottom 25% of performers. The bonus or penalty will increase up to plus or minus 9% by year 2022. Remember, it is budget neutral and bell curved, so there will be as many losers as winners. Now, that said, most performers will fall into the middle, either receiving a bonus or a penalty. Under MIPS, physicians are compared to each other. That's important to remember. Exceptional performers will also be eligible for additional payments. So physicians who score in the top 25 percentile are eligible to receive incentive payments from a congressional set-aside of $500 million, and that will be available through 2024. This can equal much as 10% more in fee-for-service Medicare payments annually, provided the physician or practice group remains in the top 25%. Remember, though, under QPP, most care providers will be subject to MIPS, as many of the current alternative payment models will not qualify under the new program as advanced alternative payment models. So even if you're currently in an advanced alternative – no, correction. So even if you're currently in an alternative payment model, it's unlikely to be qualified as an advanced under QPP. So most people will be subject to MIPS. Okay, so finally, your scores will also be published on the CMS Compare website. So if you're in a group, what your group does as a whole will be attributed to you as an individual. That means if you are employed by someone else, you need to know who is in your group. Now, OGS has asked CMS to rethink this group attribution. You will be able to review your score 30 days prior to it being uploaded, and you can let CMS know if you disagree. I know a lot of this sounds daunting, but remember, you are already doing much of this in some form already. Now, Bob is going to talk to you about how you can prepare, and in order to make sure we get through the presentation, we'll wait on answering questions about the MIPS program until Bob is done. But if you have questions, you can go ahead and type them now, and Leslie will start looking at them. Thank you. Well, good evening, everyone, except for those on the West Coast where it's good afternoon. So what I'm going to do is kind of look at it from a practitioner's position and say, what can you do to prepare and really operationalize this in your practice? So first thing I'd like to mention is that I developed this flow chart to kind of help people, lead people in which direction they should go, because currently in the United States, there's about 855,000 physicians with 810 physicians providing care, patient care. And of those 810 physicians, about 250 of them are employed. Another 290,000 of those physicians have some contractual arrangements with a hospital. And I guess what I'm trying to bring up is that it's going to be a different world if you're a hospital-employed physician, because there is a lot of stickier issues, such as anti-stark and anti-kickback issues that will probably come into play. And the other thing, though, we're not hospital-based physicians. There's no accommodations for that. So it could get very sticky trying to discuss what an employed physician should do. So we're kind of going to go to the other side and say, okay, you're not employed at a hospital, so you're either an individual or a group practice. And as far as I know, and maybe somebody can correct me if I'm wrong, Euroguides don't really participate in any of the alternative payment programs right now. But if you do, you probably wouldn't qualify anyway, because what you would do is that you would apply, and then CMS would look and see if you're either a qualified provider or a partial qualified provider, and then allow you to use the APM mechanism. So most of us will go under the MIPS, and then you'll need to decide whether you go into the program as an individual or group, as previously mentioned. So what I'm going to do is kind of give some basic tips on how to prepare. And I think the most important thing is to educate yourself. And there's a lot of education going on, and what I wanted to do was kind of direct you on who I think is on the forefront of keeping their physicians advised of the changes. So obviously you're on this webinar, and so you're getting updates from your organization. Another good site, if you're in practice, is MGMA, and some of the information that I've used for this talk is from MGMA, and some of it's from the AMA. Another good source, if you're a hospital-employed physician, is looking at the American Hospital Association, because they're looking at it from the standpoint of, okay, we have these employed physicians, how are we going to change things so that we can maximize the bonus? And the one thing I will warn you is that you need to be educated on this, because it's still your tax ID, it's still your MPI number that they're billing under, and if any untoward activities get found out, it's actually you as the physician that gets excluded out of Medicare and Medicaid for two years. So you have to be on top of what the hospital is doing. Then obviously CMS is the go-to for all the updated and current information. The second thing I'd like to point out is that it is a work in progress, but you can't delay preparing for it. So what I would recommend is that, like I have emails or texts sent to me on any kind of update, depending on what organization that you belong to. And so, for example, I got an email today stating that one of the sponsors of the bill, which is actually Phil Rowe, who's an OB-GYN, has recommended that there's a six-month delay in actually reporting the information. And the American Hospital Association has also asked for that, because there's a feeling that the independent practitioner may be put at a disadvantage. So you need to monitor these changes, because it can change on a dime. The other thing that you'll want to do is try to review your current baseline in terms of these measurements you're going to be doing. So current quality measurements and reporting. And you can actually go to the CMS.gov site and obtain what's called a QRUR, which is a Quality and Resource Use Report. So you'll have to get an account, and you'll be able to look at your own or your group's data that CMS actually keeps track of. Another important thing to do is to really look at the EMR that you have currently. And there's several reasons for that. But it's like anything else. If your EHR is not adequate, it's garbage in, garbage out, and it could negatively affect your data reporting. So first thing is you actually need to make sure that your EHR is adequate. You actually need to make sure that your EHR is going to be certified. On top of that, as mentioned, 15% of your score is from this Advancing Care Information category, and you have to get 70% to actually get credit for that. And what they're asking, especially with hospital-employed physicians, if there's a way that they can align, the hospital can align their Meaningful Use Program with the employee physician's Meaningful Use Program so that there's not double reporting. So that's something to keep track of. The other thing is that it's not mentioned until you read the AHA's comments, is that there's something that the physicians have to attest, what's called information blocking. And you actually have to sign these three attestations, but the one that probably is most important is that you must attest, and I'm going to quote it, you did not knowingly and willfully take actions to limit or restrict the compatibility or interoperability of their certified EHR. I'm not sure what that means, but when I see things like that, all I can see is risk. Because, you know, if you know how the OIG works, you know, they assume ignorance as the same as knowingly and willingly. So I think we'll have to kind of watch for those, because, again, we're attesting for things that, if not correct, we may get put at risk. The next thing that we'd recommend is understand your patient data, your benchmarks. So, you know, as urogynes, I think it's pretty clear what we do, but as a primary care physician, for example, you're going to want to really look at your billing data, see what your most common codes and diagnosis are to get an idea of your practice. And to get used to reporting data, if you don't belong to already, we have a pelvic floor disorders registry, but they recommend, the NGMA recommends that you join a registry to kind of get used to the process of reporting information. And, again, that's if you're currently not participating. The next thing to prepare for, and I think this is where we as urogynes can really make an impact, is what's called developing coordinated care plans. And what basically that is is that you would assess your most costly patient population's conditions and diagnosis, and what they're asking you to do is develop a targeted care delivery plan. So you may say, okay, with women coming in with stress incontinence, this is the care plan that we're going to follow. And you'll want to have a workflow that is evidence-based and that is, you know, makes sense. And here's where some potential opportunities are because you'll want to identify potential partners. So, for example, you may want to partner with other people in pelvic floor health outside of Uruguayans and develop a bundled payment system. We'll take care of people with pelvic floor disorders this way. It's already been done in terms of orthopedics and cardiology where hospitals have developed cost-saving arrangements, you know, cut the cost down of pacemakers, cut the cost down of artificial hips, but have special exclusions for the higher-cost ones. But for the most part, you know, I think we can get involved with these kind of opportunities. And the only thing that I'm a little bit worried about is that there may be some antitrust issues that Congress is going to have to address so that we can freely talk to other physicians. Because once you start talking about cost, you're sharing your billing charges and that actually is antitrust violation. And then the other opportunity is what Sage mentioned was clinical practice opportunities. And just to put a plug in for what's going to go at the annual meeting, we haven't definitively developed it, but there is going to be a QI workshop, I think Wednesday morning. And at that workshop, we're going to, you know, update people on this payment system. But also, we'll probably have a session where we'll teach you how to do process improvement, performance improvement, or process re-engineering in your office so that you can take advantage of these clinical practice opportunities. And what we'll be pushing is the IHI model for improvement. You know, you can spend a lot of money for Lean or Six Sigma, but you really just need a simple method to improve your processes. If you're not involved with any type of value-based payment initiative, you may want to consider participating in one again just to get in preparation for an APM. And lastly, I think the biggest thing is do not procrastinate. So, ignorance is bliss, so don't let that be you. So, I think we'll open up the webinar for questions. All right. Thank you, Dr. Flora and Dr. Clayton. Just to remind you before we get to the Q&A session, the session over the next couple of days, before we get to the Q&A session, the session over the part of this program, as a reminder, the Q&A box is located on the right-hand side of your screen. To submit a question, just type your question in the small text box at the bottom, and when you're finished, you can click the Send button or just push Enter. I'll turn it back to you, Leslie, to take care of the Q&A portion of this program. Thank you, and thank you to both of you. That was really informative. I think you guys did a great job of taking some really complicated alphabet soup and new measures coming down the line and made it clear for those of us that haven't been studying this as much as you all have. I actually do have a question. In terms of these enhancing your clinical practice, and Sage, I think you touched on this, but how is that gonna be measured? Do we have to pick from something and then they just ask us if we're doing it or not? Or, I mean, are they gonna be measuring those practice kind of enhancement protocols? Well, there's a list of 90, you're talking about the clinical practice improvement activities, right? I am, I am. How are they gonna know if you're doing it or not or measure that? Yeah, so there is a list of 90 of them that we're supposed to do, and so far CMS hasn't given us really good specifics. They're just like, here's a list without much direction. On the quality committee, we've been talking about possibly putting guidelines up on the OGS website of recommendations of how to do that. But in terms of how to report back to CMS that you have done it, we haven't gotten good direction on that so far, and I don't know if Jill or Bob has had a, has had a chance to, like, a recent missile from CMS to tell them if they've changed that yet or not. Jill, do you know? So CMS has given a little bit, Sage is exactly right, a little bit of information, but not enough to actually get the job done. So in the MACRA proposed rule, CMS mentioned that they would be creating a system, we're assuming it's gonna be a web-based portal, but they didn't say that, where physicians could go and attest to the fact that they had done one of these 90 listed activities and that they had done it for at least 90 days. CMS is proposing for the clinical performance improvement activities at 90-day attestation period that you've done the activity for at least 90 days of the 12-month period in the year. They've also offered that Qualified Clinical Data Registries over time could create the capacity to collect this information from their participants, saying whether or not they did certain ones of the activities to allow kind of a one-stop reporting place for individuals who are participating in Qualified Clinical Data Registries. So the final rule is gonna matter a lot on this activity. The other thing about this activity as Sage correctly mentioned is CMS gave us the activity, but didn't tell us what it means and what it all includes, right? So that CMS is saying they're gonna put out in what's known as sub-regulatory guidance, which is sort of what we have for all the PQRS measures. There's a big PDF on the CMS website where it gives you the measure, it gives you the numerator, the denominator, all the specifications. For reporting the measure, CMS is saying they're gonna do the same type of document for each of these clinical performance improvement activities, but again, we haven't seen that information yet from the agency, which is why, as Bob mentioned, the AMA, AMG, AMGMA, other groups, OGS as well on our comment letter asked that we at least have a six-month delay to start the reporting on July 1, have a shortened reporting period for 2017, knowing that all of these fine details for you all to be able to plan and be successful, we might not even get them till November 1st, maybe even later, and that's not enough time. So we'll see what CMS is going to do. Maybe they would shorten the reporting periods, but they'll start January 1 or give you an option to report on different time periods within the year or start later, but hopefully they'll do something to help out. Yeah, this is Bob. I just wanted to add, and Joe, correct me if they've changed it, but of those clinical practice activities, they basically made nine subcategories, which I think the 90 fall under one of them. So they're expanded practice access, population management, care coordination, beneficiary engagement, patient safety and practice assessment, achieving health equity, emergency response preparedness, and integrated behavioral and mental health, which is kind of crazy since they don't even pay for that stuff, but that's another story. Right, and some of those categories are required by the law. MACRA actually laid out categories that CMS needed to work with the specialty sites to develop clinical performance activities, and some of those categories are ones that CMS wanted to add on their own. Also, the law, the regulation, excuse me, talks about how CMS needs to set up a process to take additional nominations for new clinical performance improvement activities or additional clinical performance improvement activities from the medical specialty societies, but they have not expanded on how we would nominate an activity and what the process and criteria would be for selection of that activity, but there is some concern of how we could add new activities, particularly if we find that our members are having trouble getting to the 60 points needed to get the entire 15% of the clinical performance improvement activity score into their composite. Thank you for that. So I think this has sort of been maybe a pattern where some of these initiatives are mentioned and some of the goals, but exactly how to get there is still a little murky, and one of the things I struggle with a little bit is that, you know, I've been to some of these talks and I'm part of an academic institution. Within that academic institution, there's a medical group, and so a lot of, I think some of the regulatory requirements are overseen by the hospital and then mandated and maybe embedded within your electronic medical system to make sure you're meeting certain things in the hospital. You get scorecards and that kind of thing. But my practice, my little Euroguide practice is for people. So are there, and you kind of alluded to this a little bit, that in a large group, you might be sort of measured by the whole instead of by yourself or your three partners. So are there things that we could be doing at that, one, are there things we could be doing at that small part of the practice level that are impactful, and two, does it matter when you're being measured amongst the five times as many or 10 times as many, for instance, internal medicine docs? Like are you being measured by their performance or are there things you can do at your small practice level that matter? So one of the things that you could- Yeah, Sage, you're a good person to answer that question, given your practice setup. So one of the things that you could do is find out if you guys are all in the same tax ID. If you are, so some of the large universities will have five or six tax ID numbers and figure out whose tax ID number you're sharing. And you can look to see, again, it might be you and general surgeons, if that would be an ideal situation. And so there's some things you can do together. So if the four of you decide to join the OGS Registry and you're the only four urogynes or the only four gynecologists, then every time one of those care episodes comes up and you guys are hitting it all the time, you'll bring your entire group up for the measures involved in the OGS Registry. So now you're participating with, you're bringing the cardiologist up or whoever else is in your tax ID number. If you're in a tax ID number with the, just one for all of Yale, then it's tougher and you're kind of stuck leaning on your colleagues for now. CMS has talked about and OGS has petitioned that we unbundle the NPI number from the tax ID number just because one of the focuses when they made the rule, one of the things they were looking at was how can they better assess physicians as individuals? And certainly if you're in a tax ID number with a bunch of primary care physicians and you're not doing breast exams and diabetic foot exams and who else knows, there's not really a good way for CMS to assess the care you're providing and they're gonna get a whole lot of complaints when they post that on the website, when they post your quality metrics on the website because they really don't apply to you. So the good place to start is just find out who's in your tax ID number right now for the next two years at least while CMS kind of sorts these things out. That's a great tip. No, I think that's helpful and then it can also help guide you with maybe who to partner with within your hospital or within your medical group if you have a really large medical group. I wanted to explain a little bit when you mentioned joining the OGS registry, can you explain in the scenario that I gave you, how does that, when you said it's gonna benefit, how does that help exactly meet some of these quality indicators? So Sage can talk about, I'll mention in a minute. Many medical society, including OGS, are taking their registry through a program called Qualified Clinical Data Registries which is a program that was actually created in the Medicare legislation for the SGR two years before MACRA was done and that program allows registries to get certified with CMS such that then the individuals who are reporting into that registry would then have their quality measures, that registry would be responsible for putting in all the data on their quality measures and as part of that application, you put in what quality measures are being collected in the registry and that CMS can expect to get from any participant in the registry. Now we have this additional possibility of the 90 clinical performance improvement activities that CMS selected, about, what, 12 of them, Sage, are registry-centric, i.e. activities you would do potentially with a Qualified Clinical Data Registry and as you saw in Sage's slide for the, I still call it meaningful use, but the electronic health record piece, you saw that one of the areas around that scoring system includes participating in a clinical specialty registry. So as you can see, there's a lot of layering about how registry participation is a way to help you with your MIPS participation. Great, thank you. So even for AUGS members that are part of a hospital system or an academic institution, there is still benefit to joining the AUGS registry? Sure, because as Sage has pointed out, is that if your group at your academic institution is smart and getting prepared, like Bob brought up, you will be sitting down with the leadership of the faculty practice plan looking at which specialties have the best registries relative to how your faculty practice plan would be able to report and would be able to do such that you would have the best possibility of getting good scores for the composite score calculation if you're reporting as a group. So some registries are probably more elaborate, maybe harder than others, maybe less integrated with the electronic health record versus the new registry that AUGS is going to launch at the annual meeting. So those are the types of assessment things as Bob was talking about that everybody needs to be doing now if they're in a big group. Maybe AUGS members, when you look at the AUGS developed quality measures, they would do better in regards to the benchmarks on those measures than say cardiology is doing on their measures. So then the whole group would say, okay, well, we're gonna then count on our OBGYN department to bring us home here through our group and the other specialties are gonna come along for the ride and support the urogynes bringing it home for the whole group or vice versa. Maybe you pick to do the qualified clinical improvement activities through the AUGS registry, you actually report your quality through another registry and you have certified vendor on meaningful use through another activity. So you could also parse them out, you just have to do it all under your group number in regards to the activities, but it doesn't all have to be done with the same supports. Yeah, Joe, if I can add to that too, especially if you're in a group and then a multi-practice group, you're probably gonna need help. One of the things that I have, I have a finance guy at my disposal, but one of the things that you're gonna have to do, like what Jill mentioned, okay, it's advantageous to join this registry, it's not for this. You'll have to have a finance person do what's called a sensitivity analysis where basically they look at all the scenarios and then they'll lay out for you what the best choices are. We tend to think in black and white and when you get the finance people in there, they can give you all the grays so you can make a better business decision. So to be honest with you, I wouldn't go this alone. I'd get some finance person to help you kind of do a perform on what the best choices are. A lot of big groups have always assumed that reporting the primary care type measures for a big group was going to get them through. And what we found with the 2016 scores for the large groups, i.e. over 100, eligible professionals, which is physicians, ODs, nurse practitioners, PAs, et cetera, is that many of them actually got the penalty. And so Bob is exactly right. It may not be that the general kind of primary care type measures in the quality programs are actually going to be ones that are the best for your group. You really have to do the scenario work and find out and pick your best measure set for your big group because the score from the group will be attributed to every individual clinician, every individual eligible clinician in that group, and you will all sink or swim together. And so your score will come from your group's activity, but it will be compared and laid up against every other physician in the Medicare program. So if your group has a bad overall score and it gets attributed to everybody in your group, your entire group's gonna fall down to the bottom. So it's really important that you find out, as Sage said, who's in your tax ID number, what's the controlling body for your group, what are the committees in your group, what access do you have to financial resources, i.e., as Bob was saying, the scenarios, and do it now, do it this summer, do it this fall. Start having meetings, start getting together, getting organized, getting your administrative people with you and not assume that it's going to work out for you if you don't ask around and get it going. Be the instigator, so to speak, in your big group and make sure that folks are getting ready and you can serve on committees in your group or whatever help you can provide. Yeah, the AMA was really kind of pushing to get your QRUR or the Quality Resource Use Report because what they said, it'll kind of give you an idea of how CMS looks at you, but it also gives you ideas on where you can improve. While I'm waiting to see if any of the participants want to type in another question, I did wanna answer one question that came up about how to be able to see the slides. Somebody actually asked that, how can we obtain a copy of the slides? I'm not sure about that, but all of these webinar presentations are archived on the OGS website. If you go to the main OGS website and go into the Education tab and then under FPMRS Webinar Series, at the very bottom of the page, at the top of the page, it shows upcoming webinars. At the very bottom, there is a link to click for archived webinars, which is mostly clinical topics and advanced learning objectives, but also, like we said, it expanded to include some of these practice topics also. So, if nobody else has any other questions to add, I guess we have just a few more minutes left. I would ask our presenters if they have any. Oh, wait, one just came up. How can the individual start to prepare? And I'm not sure whether you mean someone that's in solo practice or how you would engage maybe your partners if you're in a smaller practice. But the question, solo practice. So, how can someone in solo practice start to prepare? First thing is, yeah, Bob, help him out. Poor, that's gonna be some work. Well, so to be honest with you, well, let me just ask you one question. You're solo but not employed by the hospital? Okay. Solo, not employed by hospital. Okay, well, so as I had mentioned, it's a moving target, but you probably are a little bit in more of an advantageous position because you only have to worry about yourself. And so, basically, what I would say is kind of look and get all your data now. To just kind of know where you are. But what it'll do is it'll kind of get everything ready so that when you have to start making these decisions like what am I gonna do about clinical practice improvement? But just the basic stuff. Just make sure your EHR is certified. Because if your EHR is not able to generate the data that you need, you know, what I would say is no data probably counts as no care or no good care. So you really need to just make sure you have all the pieces together in your practice, which, again, my dad was a solo OB-GYN. It's always better because you're your own boss. You don't do that. But if you go to the AMA website, it actually has a checklist that you can use. And then I think you can go to the NGMA website and it's, I don't think it's protected. I don't think you have to sign in as a member, but they also have a checklist. And that's actually what I use to develop these slides is the two checklists. So they really have things out there to kind of help you make sure you're going through every step. But just understand it could change on a dime. I think you want to definitely checklists, and OGS is going to be developing some that are specific to our measures and activities. Also, absolutely talk to your vendors for your EMRs and make sure they are certified to the appropriate level of standards. The 2014, more likely try to get them to the 2015 Office of the National Coordinator EMR standards. Really important because many of the elements of the Meaningful Use 25%, if you're a certified system, if your system is certified, the vendor's going to get you where you need to go. The other thing is to really stay in touch with OGS about the launch of the new quality registry at the annual meeting because as a solo person, that would help you do your quality reporting and it would help you do your clinical performance improvement activities. And I would also download your QRUR report so you can see any data in the current quality programs that CMS has attributed to you so you know where you're sort of starting. Yeah, and the instructions to get that report, if you go to CMS.gov, that's what I actually cut and paste on the one slide. It has instructions on how to get your sign-on password. Some of the slides, too, we borrowed a lot of our slides from CMS.gov so you'll see similar slides, maybe a few more if you go there. And you can spend some time, in addition to on the OGS site, but you can spend some time looking at those and absorbing them, too, if you didn't, if you feel like you want to go do that as soon as possible, that you'll see similar-looking slides to the OGS website. Yeah, you just do www.cms.gov, and then in the search box, just type in MACRA, M-A-C-R-A, and the very first pop-up is a MACRA web page, and you want to click on that. And as Sage said, it has lots of good information, and it'll have more. So it's a good one to bookmark because it will have more over time. That's where CMS is going to be putting all of the QPP information. Well, you know, we are out of time, but there was one other question that came up, so I'll just ask it if we could give a brief answer to it. But there's a question asking, are all of these measures self-reported? And if so, how often, and how is it monitored by CMS? So, if you go to... So, yes, all of the measures are self-reported. If you go to... So, yes, they're self-reported either through your registry, through your EMR, or if you put them in as part of your billing to Medicare. Currently, with PQRS, you know, you've picked your measures, and those measures, we have a... They're on CMS, but I think we have a list on the Ogg site, too, under quality of which ones are the Ogg-specific ones. That's right. Yeah, so... But you have to report them. You can do them as you go, so as you see a Medicare patient, or you can do them all at once if you're, like, you know, have a whole bunch of time that you want to sit down and spend 17 hours going through all your last year's worth of patients. And I think the deadline for each year, isn't it, like, December, maybe, Jill? Well, so the vendor, or yourself, have until usually March 31st of the following year to make sure you can get all your December people uploaded and in and ready to go. But one of the things, unfortunately, that CMS proposed in the MACRA proposed rule was to up the percentage of patients under the measure that you would have to report on to be successful. Right now, it's 50% of all the patients who qualify under the measure, i.e. they're in the denominator for that measure under PQRS, have to be reported. CMS is trying to up that ante to 80% for claims and 90% for registries, thinking that it's easier for physicians and other eligible clinicians to just report on every patient versus picking and choosing patients. I would kind of disagree with them on that, just for the sense that many of you may go to multiple hospitals or provide care in multiple offices, and you might decide it's easier to, like, pick two of your sites versus all four of your sites or whatever. But so that's something everybody needs to be aware of, is when you self-select your measures, one, are they registry-only measures? And many of the measures are now because that's what CMS wanted for measure developers to do. And two is what the specifications are for the denominator, i.e. what patients is that measure attributed to? Thus, you would have to be able to know. You could easily find those patients in your charts, et cetera, so you would get them reported on. So those are the types of considerations in regards to which measures are the best measures for your practice to consider selecting under MIPS reporting. So I think we are at our time limit for the day. I really wanted to just give a big thank you to Drs. Flora and Clayton and also to Jill Rathburn for coming on and for everybody's fantastic presentation. I think this webinar series is a great platform for highlighting the range of expertise across our subspecialty. I also want to thank all of the participants for carving time out in your days to participate in this virtual forum with our speakers and with each other. Upon completion of this program, you will be prompted to provide feedback, so please do share your thoughts and impressions with us. And we are looking forward to our next program on August 17th at 7 p.m. Eastern Time. Dr. Nazima Siddiqui from Duke is going to be giving a webinar on robotic surgical training for residents and fellows, ways to optimize the training experience with dry lab and simulation curricula. So I think this will be great for anybody involved with either teaching trainees or somebody who's interested in learning robotic surgery or somebody that's involved with training. So with that, again, a big thank you to our speakers, to Blue Sky, and also to the participants, and that's it for the evening.

Quality Payment Program

MACRA

Merit-Based Incentive Payment System

MIPS

Alternative Payment Model

physician reimbursement

performance assessment

EHR capabilities

reporting performance

quality measures