MIPS: Clinical Practice Improvement Activities and the QCDR

August 16, 2016

Emily Richards, M.D., is chief Quality Officer, Encompass Medical Partners, Fort Collins, Colorado
Emily Richardson M.D., Chair Committee on Practice Quality Improvement

On April 27, 2016, the Department of Health and Human Services issued a Notice of Proposed Rulemaking to implement key provisions of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. MACRA is bipartisan legislation that replaces the flawed Sustainable Growth Rate formula by paying clinicians for the value and quality of care they provide.1 The proposed rule would implement the changes required by MACRA through a new system called the Quality Payment Program (QPP). The goal of the QPP is to continue to support health care quality, efficiency and patient safety.2 The QPP includes two provider reimbursement programs, the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Most Medicare clinicians will initially participate in the QPP through the MIPS.3 Under MIPS, the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBM) and the Electronic Health Record Incentive Program (Meaningful Use) will be rolled into one program. In addition, a fourth component, Clinical Practice Improvement Activities (CPIA), will be added to promote ongoing improvement and innovation in clinical practice. There has been much speculation as to what the potential role of Qualified Clinical Data Registries (QCDRs) within the MIPS and specifically within the CPIA performance category will be. The purpose of this article is to provide an overview of the CPIA requirements and describe how participation in a QCDR can help meet those requirements.

Under MIPS, health care providers and groups will be paid for delivering high-value care based on their performance in the following four categories: Quality, Cost, Advancing Care Information and CPIA. Weighted performance scores in these four categories will be used to calculate a single Composite Performance Score (CPS) on a 0-100 point scale. The CPS will be used by the Centers for Medicare & Medicaid Services (CMS) to determine whether a physician receives an upward, neutral or downward payment adjustment to their Medicare Part B payments.3 Like the PQRS, the payment adjustments will take effect two years after the performance period.

 “In the coming years, QCDRs will be

allowed to define specific CPIAs for

clinicians or groups through an

established approval process.”

The performance period for year one of MIPS will begin January 1, 2017, and the data collected will affect payments in 2019. The MIPS also affects a similar group of identified health care providers. These providers will be referred to as MIPS-eligible clinicians (ECs) instead of eligible professionals (EPs). For the first year of the MIPS, eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. Under the proposed rule, CMS defines those clinicians who bill for 25 or fewer patient-facing encounters, such as office visits, outpatient visits and surgical procedures, as non-patient-facing clinicians. MACRA allows for special consideration to be given to these clinicians under MIPS.2

Expanding the Role of Qualified Clinical Data Registries

MACRA legislation specifies that the use of QCDRs should be encouraged under MIPS.4 Through the proposed rule, CMS has described an expanded role for QCDRs within three of the four MIPS components. The proposed rule allows for QCDRs to report on the quality, advancing care information and CPIA performance categories. Administrative claims data will be used to calculate the Resource Use score, thus eligible clinicians will not need to report additional information for this category. This approach is meant to reduce administrative burden and simplify the data submission process for MIPS-eligible clinicians by having a single reporting mechanism for all three performance categories.2

Clinical Practice Improvement Activities and QCDRs

MACRA defines a CPIA as an activity that eligible clinician organizations and other relevant stakeholders identify as improving clinical practice or care delivery and that is likely to result in improved outcomes.4 For this category, MIPS would reward clinical practice improvement activities focused on care coordination, beneficiary engagement and patient safety.3 Eligible clinicians would select activities from a list of more than 90 options referred to as the CPIA Inventory. A clinician’s score in this category would be determined by weighing the activities on which they report. Highly weighted CPIAs would be worth 20 points, while other activities would be worth 10 points. The maximum total points rewarded in the CPIA category would be 60. Eligible clinicians or groups that select fewer than the required number of CPIAs would receive partial credit. If a MIPS-eligible clinician or group reports no CPIAs, then the clinician or group would receive a zero score for that category. The eligible clinician or group must perform CPIAs for at least 90 days.2

Many of the available CPIA activities are specific for patient-facing clinicians. CMS will allow non-patient-facing clinicians or groups to earn 30 points per activity, regardless of whether the activity is medium or high.

Non-patient-facing MIPS-eligible clinicians and groups can therefore report on one activity to achieve partial credit or two activities to achieve full credit to meet the CPIA submission criteria.2

The proposed rule allows for data for the CPIA performance category to be submitted by qualified registry, electronic health records, QCDRs or by CMS Web interface. CMS has placed a priority on the use of QCDRs as a reporting mechanism, and working with a QCDR would allow a clinician or group to report activity for multiple CPIAs. Regardless of the data submission method, all MIPS-eligible clinicians or groups must select activities from the CPIA Inventory provided in the proposed rule.

Within the CPIA Inventory, there are several activities that could be appropriately reported by anesthesiologists. Examples of activities that anesthesiologists could report for CPIA credit include2:

  • Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes.
  • Participation in a QCDR, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement.
  • Participation in a QCDR, demonstrating performance of activities that promote implementation of shared clinical decision-making capabilities.
  • Use of QCDR data for ongoing practice assessment and improvements in patient safety.
  • Regular assessment of patient experience of care through surveys or other mechanisms.
  • Participation in Maintenance of Certification Part IV for improving professional practice.
  • Participation in Joint Commission Ongoing Professional Practice Evaluation (OPPE) initiative.
  • Adoption of a formal model for quality improvement and creation of a culture in which staff actively participates in improvement activities.

In the coming years, QCDRs will be allowed to define specific CPIAs for clinicians or groups through an established approval process.2 Additional measures and activities captured by QCDRs could enable specialty clinicians or groups to capture and report on more meaningful activities. In the proposed rule, CMS describes a call for measures and activities process where MIPS-eligible clinicians, groups and other stakeholders may recommend activities for potential inclusion in the CPIA Inventory. The use of QCDRs also allows for ongoing performance feedback and the implementation of continuous process improvements, ultimately enabling us to reach our goal of providing better patient care.


  1. Quality Payment Program. Centers for Medicare and Medicaid Services website. https://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/ MACRA-MIPS-and-APMs/Quality-Payment-Program.html. Accessed 6/3/16.
  2. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) incentive under the Physician Fee Schedule, and criteria for physician-focused payment models; proposed rule. Federal Regist. 2016;81:28161-28686.
  3. Notice of proposed rule making: Quality Payment Program. Centers for Medicare and Medicaid Services website. https://www.cms. gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/NPRM-QPP-Fact-Sheet.pdf. Accessed June 1, 2016.
  4. Medicare Access and CHIP Reauthorization Act of 2015. Pub L No. 114-10. Congress.gov. https://www.congress.gov/114/plaws/publ10/ PLAW-114publ10.pdf. Accessed June 3, 2016: Pages 129 STAT 96 – 129 STAT 99.

ASA Monitor “MIPS: Clinical Practice Improvement Activities and the QCDR” (Richardson E. [2016; 80(8): 50-51]) is reprinted with permission of the American Society of Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173.

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