- [Anna Cupito] Hello and welcome to this presentation.
My name is Anna Cupito, and this presentation
focuses on how doctors and clinicians
can preview their Quality Payment Program
- or QPP - performance information
targeted for public reporting on Medicare
Care Compare and in the Provider Data Catalog, or PDC.
Performance information available for preview
and targeted for public reporting
comes from the Merit-based Incentive Payment System -
MIPS - and Alternative Payment Models - APMs.
Next slide, please.
Please take a moment to review
the disclaimers outlined here.
The information in today's presentation
is current at the time of this recording.
This publication is a general summary
that explains certain aspects of the Medicare program,
but it is not a legal document.
Next slide, please.
On this slide, we provide a list of acronyms
used throughout this presentation.
Next slide, please.
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 2020 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 2020 performance information
due to the public health emergency.
Information under a MIPS performance category
that was re-weighted to zero through the EUC policy
will not be publicly reported.
If your re-weighting or targeted review request
is still in progress,
you will still be able to preview
your 2020 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.
Next slide, please.
The Preview Period is the first chance for clinicians
and groups to view the performance information
that is targeted for public reporting.
As we go through the presentation,
I'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 and MIPS APM participants
who voluntarily 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.
I will go over how to preview your
or your group's information later in this presentation.
Next slide, please.
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 and Systems
- or CAHPS - for MIPS Survey data.
Next slide, please.
Doctors and clinicians who participated
in an APM may or may not have performance information
available to preview.
Performance information from qualifying APM participants
and Advanced APMs will not be publicly reported.
However, performance information
from clinicians in MIPS APMs
and all other types of APMs will be publicly reported
if the information was selected for public reporting
and did not have the EUC applied to them.
Next slide, please.
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 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 login 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.
Next slide, please.
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 which 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.
Next slide, please.
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 what 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 selected 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, Belen Michael,
to explain what information is available to preview.
Belen?
- [Belen Michael] 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 targeted 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 category.
Next slide, please.
On the quality page, there will be one or both
of the tabs shown on this slide.
"Performance" and "Patient Survey Scores".
This is where you will review
your quality performance information targeted
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 in groups
with MIPS or QCDR quality information to preview.
The "Patient Survey Score" tab only displays
for groups that have CAHPS for MIPS
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 are available
on the Care Compare: Doctors and Clinicians Initiative page.
Next slide, please.
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 checkmarks.
There will also be an indicator if you or your group
attested negatively to one or more
of the prevention of information blocking attestations.
This 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 a group's profile page.
Next slide, please.
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.
Next slide, please.
On this page, you can preview
a list of improvement activities
that are targeted for public reporting on your profile page.
The improvement activities display as green checkmarks.
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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 a downloadable format.
Select "Provider Data Catalog"
from the left-hand navigation
to see what information will be published
for you or your group.
Next slide, please.
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 from the Preview pages.
Because the information is not yet publicly reported
and this is intended only to be
a preview of the information,
you cannot download the data set.
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
targeted for public reporting on profile pages
as well as additional performance information
that is targeted for public reporting
but was not selected for profile pages.
The Final Score and Performance Category Scores Database
contains MIPS final score 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
targeted for public reporting on profile pages,
as well as additional performance information
that is targeted for public reporting
but was not selected for profile pages.
CAHPS from MIPS scores
are in the Patient Experience Database.
Next slide please.
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.
There are two scenarios in which you or your group
may be eligible to opt out.
First, if you are a clinician or group
that submitted MIPS performance information
but were not MIPS eligible during the performance year,
you can opt out of having
performance information publicly reported.
And second, if you are a clinician who participated
in a MIPS APM during the performance year,
you can opt out of having measure-level
and attestation-level performance information
reported during the Preview Period.
However, your MIPS final score
and performance category scores
will be publicly reported
in the Provider Data Catalog.
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 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 2020 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.
Next slide, please.
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.
Next slide, please.
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.
Next slide, please.
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.
Next slide, please.
After selecting "CONFIRM",
please verify that the opt-out was successful.
At this point, you'll 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 questions about the Preview Period
that we didn't answer,
or if you have feedback on what we presented here,
we encourage you to reach out
to the Quality Payment Program 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,
and we look forward to continuing to work together.