- [Anna] Hello and welcome to this presentation.
My name is Anna Cupito,
and I'm joined by my colleague, Courtney Hall.
This presentation focuses on how doctors and clinicians
can preview their Quality Payment Program, or QPP,
performance information planned
for public reporting on Medicare Care Compare
and in the Provider Data Catalog, or PDC.
Performance information available for preview
and planned for public reporting
comes from the Merit-based Incentive Payment System, MIPS,
and Alternative Payment Models, APMs.
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Please take a moment
to review the disclaimers outlined here.
The information in today's presentation
is current at the time of this recording.
The publication is a general summary
that explains certain aspects of the Medicare program,
but it is not a legal document.
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On this slide, we provide a list
of acronyms used throughout this presentation.
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Before we continue,
we do want to note that we understand doctors and clinicians
have been greatly affected by the COVID-19 pandemic.
To address this public health emergency and its impact,
we want to point out a few things.
All of the MIPS 2021 performance information
that will be previewed and eventually publicly reported
has met the established statistical
public reporting standards.
The standards require that measures
are statistically valid, reliable, accurate,
and comparable across submission mechanisms,
and meet the minimum reliability threshold.
The Extreme and Uncontrollable Circumstances, EUC,
exceptions were automatically applied
to MIPS eligible clinicians
and available to groups
who experienced challenges collecting or submitting
2021 performance information
due to the public health emergency, or PHE.
Information under a MIPS performance category
that was reweighted to zero through the EUC policy
will not be publicly reported.
If your reweighting or targeted review request
is still in progress,
you will still be able to preview
your 2021 performance information
through the Preview Period.
If your performance information, including Final Score,
changes as a result of the targeted review,
please view your updated performance feedback.
You can do this through the QPP website,
just look for the Performance Feedback link
in the QPP dashboard.
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The Preview Period is the first chance
for clinicians and groups
to view their performance information
that is planned for public reporting.
As we go through the presentation,
we'll share more details on how to know
if you or your group has information available
for public reporting and how to preview that information.
Please be aware, the Preview Period
is not only for MIPS eligible clinicians and groups.
Voluntary reporters,
meaning those who were not MIPS eligible,
but still submitted performance information,
can also preview their performance information.
During the Preview Period,
voluntary reporters who submitted performance information
are able to opt out
of having their performance information publicly reported.
MIPS eligible clinicians and groups cannot do this.
Please note, if a voluntary reporter has opted in to MIPS
for the purposes of a payment adjustment,
they will not be eligible to opt out of public reporting.
These reporters' performance information
will be publicly reported.
Clinicians and groups will be able to preview
their performance information during the designated period
by accessing the Doctors and Clinicians Preview section
of the QPP website.
We will go over how to preview your
or your group's information later in this presentation.
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This slide shows the types of clinicians and groups
who should preview their performance information
on the QPP website.
This includes eligible clinicians,
groups, and virtual groups
that submitted MIPS performance information,
clinicians, groups, and virtual groups
who are not MIPS eligible
but voluntarily submitted MIPS performance information,
and groups that submitted
Consumer Assessment of Healthcare Providers & Systems,
or CAHPS, for MIPS survey data.
ACOs should view their 2021 MIPS Performance Feedback
or 2021 Quality Performance Reports to preview their data,
as it isn't included in this preview period.
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I'll now spend some time walking through
how to log into the website
and preview your performance information.
The first step to preview your performance information
is to log into the QPP website
using your Health Care Quality Information Systems
Access Roles and Profile, or HARP, credentials.
A few housekeeping items regarding your HARP account:
if you've forgotten your credentials,
you can go to the HARP website
to recover your user ID or password.
If you don't yet have a HARP account,
please visit the HARP registration page.
Please note that to preview your performance information,
you must log in using either a Security Official
or Staff User role.
You are not able to preview your information
using a Clinician role.
Again, to log in and preview your performance information,
be sure you are using a Security Official
or Staff User role.
A Clinician User role does not allow you
to preview your performance information.
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Once you've logged into the QPP website,
you'll want to navigate
to the Doctors and Clinicians Preview section.
You can do this by selecting Doctors and Clinicians Preview
from the left-hand navigation.
You'll then be taken
to the Doctors and Clinicians Preview landing page.
Up until now, the steps have been the same
regardless of whether you want to
preview individual clinician
or group performance information.
The next steps are slightly different,
depending on what level of information you want to preview.
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To preview group performance information,
simply find the group you are interested in
and select the View Practice Details button
to be taken to the group's overview page.
Please note, if your HARP account
is connected to a virtual group,
you can preview available performance information
by selecting View Virtual Group Details
on the Virtual Groups tab.
To preview group performance information,
you must first navigate to the Practices tab
and then select View Practice Details
to preview group performance information.
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There is an additional step needed
to preview clinician-level data.
From the group overview page,
scroll down to the Connected Clinicians section
and select the View Individual Preview button
for the individual clinician of interest.
You will now be on the clinician overview page.
I'd like to reiterate that even if you are a clinician
and want to preview individual data,
or if you are previewing information
on behalf of a clinician,
you must log into the QPP website
using a Security Official or Staff User role.
Once you are on the desired individual
or group overview page,
you can start to review the performance information.
Please be aware that some clinicians and groups
may not have any performance information to preview.
This could be because none of the information you submitted
was planned for public reporting,
or because you did not submit performance information.
Again, if your HARP account is connected to a virtual group,
you'll need to follow an additional step
to preview individual performance information.
You must first navigate to the Practices tab
and then select View Practice Details,
then follow the steps shown at the top of this slide
to view clinician performance information.
I'll now hand the presentation over to my colleague,
Courtney Hall,
to explain what information is available to preview.
Courtney?
- [Courtney] Thanks, Anna.
Next slide please.
I will now walk through
each of the categories of information to preview,
starting with Quality.
To view your or your group's Quality performance information
that is planned for public reporting on profile pages,
select Quality from the left-hand navigation.
As a reminder, if you don't see this link,
it's because you do not have any information to preview
for that category.
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On the Quality page,
there will be one or both of the tabs shown on the slide,
Performance and Patient Survey Scores.
This is where you will review
your quality performance information
planned for public reporting on profile pages.
On the Performance tab,
you can review MIPS and QCDR quality measures.
Both MIPS and QCDR quality measures
are reported as star ratings.
The performance tab only appears for clinicians
and groups with MIPS or QCDR quality data to preview.
The Patient Survey Score tab only displays for groups
that have CAHPS for MIPS Survey measures
available to preview.
The measures are reported
as top-box percent performance scores.
To preview these scores,
be sure to click on the Patient Survey Scores tab.
More information about star ratings and top-box scores
is available on the Care Compare:
Doctors and Clinicians Initiative page.
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Promoting Interoperability performance information
may also be available for you to preview.
The steps for Promoting Interoperability are similar
to those for the Quality performance information.
Start by selecting Promoting Interoperability
from the left-hand navigation.
If this tab doesn't display,
it's because you don't have any
Promoting Interoperability information to preview.
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The Promoting Interoperability page
may have one or two tabs,
depending on which information
is available for you to preview,
General Information and Performance.
On the General Information tab,
clinicians and groups may see an indicator
that they were a successful performer
in the electronic health record
technology performance category,
as well as other Promoting Interoperability attestations.
These attestations are shown as green check marks.
There will also be an indicator
if you or your group attested negatively
to one or more of the prevention
of information blocking attestations.
The information-blocking indicator
is a yellow caution symbol.
Promoting Interoperability measures
are listed under Performance,
and the measures are displayed using star ratings.
The information on these tabs
is what will be publicly reported
on a clinician or group's profile page.
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Clinicians and groups
can also preview how improvement activities
will be reported on their profile pages.
Start by selecting Improvement Activities
from the left-hand navigation.
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On this page, you can preview a list
of improvement activities
that are planned for public reporting on your profile page.
The improvement activities display as green check marks.
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All of the performance information shown so far,
as well as some additional performance
and general information
not selected for reporting on profile pages,
will be publicly reported in downloadable format.
Select Provider Data Catalog
from the left-hand navigation
to see what information will be published
for you or your group.
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On the PDC page,
you'll see all of your performance information
that will be publicly reported in the PDC.
Only your or your group's information is displayed.
We are often asked if the PDC information
can be downloaded during the Preview Period.
Because the information is not yet publicly reported
and this is intended only to be a preview,
you cannot download the dataset.
We've heard this question in the past, so to emphasize,
the performance information previewed on the PDC page
is not downloadable.
While reviewing the PDC section,
be sure to expand each collapsible bar on the page.
You may have up to two bars,
depending on which information was selected
for public reporting.
For clinicians, the possible files
are the Clinician Performance Database
and the Final Score
and Performance Category Scores Database.
The Clinician Performance Database
contains performance information
planned for public reporting on profile pages,
as well as additional performance information
that is planned for public reporting,
but was not selected for profile pages.
The Final Score and Performance Category Scores Database
contains MIPS Final Scores and performance category scores.
Groups may have up to two files,
the Group Performance Database
and the Patient Experience Database.
Similar to the Clinician Performance Database,
the Group Performance Database
contains MIPS and QCDR Quality,
Promoting Interoperability,
and Improvement Activities performance information
planned for public reporting on profile pages,
as well as additional performance information
that is planned for public reporting,
but was not selected for profile pages.
CAHPS for MIPS Survey scores
are in the Patient Experience Database.
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Certain clinicians and groups are able to opt out
of having their performance information publicly reported.
Only those clinicians and groups
who are eligible to opt out of public reporting
are given that option during the Preview Period.
Many clinicians and groups
ask how they know if they're eligible
to opt out of public reporting.
This year, there is only one scenario
in which you or your group may be eligible to opt out:
if you are a voluntary reporter.
This means that you are a clinician or group
that submitted MIPS performance information,
but were not MIPS eligible during the performance year.
That is the only scenario in which you can opt out
of having performance information publicly reported.
Please be aware that clinicians
and groups who are not MIPS eligible
but opt in to the MIPS payment adjustment
cannot opt out of public reporting.
Again, clinicians and groups who are not MIPS eligible,
but who opt in to the MIPS payment adjustment,
will not be able to opt out of public reporting.
Please also note that voluntary reporting
does not apply to clinicians who participated
in an Advanced APM
and were considered Qualifying APM Participants,
or QPs, during the performance year.
I want to emphasize this decision
only applies to 2021 performance information
and does not affect public reporting in future years.
If you do not opt out of public reporting,
your performance information
will still be considered available for public reporting.
For those that the opt out policy applies to,
I'll now walk through the steps to opt out.
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The first thing you'll want to do
is navigate to the Overview page.
This is the page you get to
after selecting View Practice Details
or View Individual Preview.
If you or your group are eligible to opt out,
you'll see a link that says,
Click here to opt out of having your
MIPS performance information publicly reported.
Select this link.
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Once you've selected the link,
you'll see a screen showing the clinician or group name.
Please review this information carefully
and verify that this is you or your group.
Then, select the Opt Out button to continue and confirm.
Please remember this decision is final
and cannot be changed later.
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Once you confirm your decision,
you will not be able to opt back in
to having your performance information
publicly reported for the given performance year,
so please consider this decision carefully.
If you are sure you want to opt out of public reporting,
confirm your decision
by typing Confirm and selecting the Confirm button.
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After selecting confirm,
please verify that the opt out was successful.
At this point, you will no longer see a link
to opt out of public reporting,
instead, you'll see a message
indicating that you have chosen to opt out
of having your performance information publicly reported.
Next slide please.
This concludes our presentation.
If you have a question about the Preview Period
that we didn't answer,
or if you have feedback about what we presented here,
we encourage you to reach out to the QPP Service Center
at qpp@cms.hhs.gov.
Please know you can always find more information,
as well as the resources mentioned in this presentation,
on the Care Compare: Doctors and Clinicians Initiative page
on cms.gov.
There is a link to the Initiative page in the slides
and in the video description.
Thank you for taking the time
to access this Preview Period presentation.
We appreciate your participation and interest.
We look forward to continuing to work together.