On Jan. 1, 2017, the Centers for Medicare & Medicaid Services (CMS) launched the Medicare Quality Payment Program (QPP) with the goal of rewarding high-value, high-quality Medicare clinicians with payment increases, while reducing payments to clinicians who do not meet performance standards.

The QPP consists of two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

Clinicians are encouraged to participate in the track that best suits their practice size, specialty, location, and patient population. Currently, MIPS has a higher participation of clinicians, although CMS intends that more clinicians will move to the Advanced APM track and receive the 5 percent performance bonus.

Further, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) statute was updated in sections by the Congress in the Bipartisan Budget Act (BBA, 2018), which was signed into law in February and created greater flexibility for potential regulatory changes. We expect annual rulemaking on the QPP.

It is important for AAOS and its members to frequently revisit MIPS and highlight best practices from orthopaedic practices, because QPP remains the most important reporting and payment program for clinicians who see Medicare patients.

The following interview highlights MIPS implementation issues and solutions for orthopaedic surgeons and their practice staff. Erika Gandee is a project manager at OrthoCarolina, a multispecialty orthopaedic practice with 42 locations in North and South Carolina. Ms. Gandee is responsible for submitting MIPS measures to CMS and ensuring that OrthoCarolina is in compliance with the MIPS reporting requirements to avoid penalties. She spoke with AAOS Now about her experiences with MIPS.

AAOS Now: In which quality improvement measures did OrthoCarolina choose to participate, and why?

Ms. Gandee: OrthoCarolina chose to participate in the following six measures:

1. Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
2. Documentation of Current Medications in the Medical Record
3. Falls: Screening for Future Fall Risk
4. Tobacco Use and Help with Quitting Among Adolescents
5. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
6. Pneumococcal Vaccination Status for Older Adults

As a specialty practice,
Ortho­­Carolina chose measures that were relevant to its patient population under the Physician Quality Reporting System. We carried the measures forward for the quality category for MIPS. We feel our selected measures also provided essential information for patients’ plan of care.

AAOS Now: What steps did you take as a practice to prepare for the transition?

Ms. Gandee: We proactively established internal benchmarks in 2012 under Meaningful Use Stage 1 that exceeded the thresholds set forth by CMS. This continues to help our organization achieve compliance.

AAOS Now: Does your practice submit bonus credit measures?

Ms. Gandee: We submit bonus credit measures through our registry, Oberd, which is a Qualified Clinical Data Registry.

AAOS Now: How many full-time equivalent hours do OrthoCarolina dedicate to QPP reporting?

Ms. Gandee: About 10 hours per week.

AAOS Now: Do you have any insight on how your performance score will be impacted if the cost category weight in the total MIPS score becomes 30 percent next year?

Ms. Gandee: We have implemented a Bundled Payments for Care Improvement program that helps increase quality of care and decrease healthcare costs for Medicare patients. We believe that this, along with other surgical optimization programs like the Coordinated Care Program, our own commercial prospective bundle program, will positively impact the cost category.

AAOS Now: What protocols have you put in place to fulfill the security risk analysis measure?

Ms. Gandee: We have various policies, plans, procedures, and processes to ensure compliance with [Health Insurance Portability and Accountability Act] security as well as information technology best practices. These measures include network segmentation, hardware firewalls, anti-malware (multiple layers/systems), encryption, backup/disaster recovery processes, password complexity rules, role-based security (based on job classification), employee acceptable-use policies, formal vendor management, system timeout intervals, privacy screens on computers in public areas, business associate agreement, and more. They are all reviewed as part of an annual security risk assessment. They are also reviewed as major changes are made to the environment, as security and risk incidents surface within the industry (both health care and technology at large), and when changes to the management structure occur within our practice.

AAOS Now: How do you document these evaluations and improvements?

Ms. Gandee: We implemented a formal methodology in which one or more engineers creates a specific and detailed specification document for a proposed change and a separate engineer or engineers review and implement those changes. The specification document becomes the basis for documentation of the changes made, and that documentation is saved in a Wiki-style knowledge base that is available as needed to the engineering team.

AAOS Now: Do you have any lessons learned or pearls of wisdom gleaned from your 2017 reporting?

Ms. Gandee: We feel that continuous monitoring of the data throughout the year helped ensure our numbers were accurate, and it also helped us meet the internal threshold set forth by our physicians.

Cindy Bracy is manager, practice management affairs, in the AAOS Office of Government Relations. Peter Pollack is a former senior staff writer for AAOS Now.