- [Allison] Hello, and welcome to this presentation.
My name is Allison Newsom
and this presentation focuses on how doctors
and clinicians can preview their Quality Payment Program
or QPP, performance information
that's 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.
Please take a moment
to review the disclaimers outlined here.
The information in today's presentation
is current at the time of the recording.
This publication is a general summary
that explains certain aspects of the Medicare Program,
but it is not a legal document.
On this slide, we provide a list of the acronyms
used throughout the presentation.
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 effects,
we want to point out a few things.
All of the 2019 MIPS 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 available
to those MIPS eligible clinicians
who experienced challenges collecting
or submitting 2019 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.
Lastly, the 2019 Preview Period has been extended
from 30 to 60 days to allow more time for doctors
and clinicians to preview their performance information.
The Preview Period is the first chance for clinicians
and groups to view their performance information
that's 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.
Note, if a voluntary reporter
has opted into the MIPS program
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
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.
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.
Doctors and clinicians who participated in an APM
may or may not have performance information
available to preview.
Performance information from qualifying APM participants
in 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.
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 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 do 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 were using a security official
or staff user role.
A clinician user role does not allow you
to preview your performance information.
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.
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.
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.
There is an additional step
needed to preview clinician level data.
From the group "Overview" page,
scroll down to the "Connected Clinician" section
and select "View Individual Preview".
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 were previewing information
on behalf of a clinician,
you must long 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.
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.
And 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".
From there, follow the steps shown at the top of this slide
to view clinician performance information.
Now I'll 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 that category.
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 and groups
with MIPS or QCDR Quality performance
information to preview.
The "Patient Survey Scores" tab only displays
for groups that have CAHPS for MIPS measures
available to preview.
The CAHPS for MIPS 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.
Promoting Interoperability performance information
may also be available for you to preview.
The steps for "Promoting Interoperability"
are similar to those for Quality performance.
Let's 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.
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
displayed 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.
The information blocking indicator
displays as an orange 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.
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.
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.
All of the performance information shown so far,
as well as some additional performance
in general information that was 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.
On the PDC page,
you'll see all of your performance information
that would be publicly reported in the PDC.
Only your or your group's information is displayed.
We're often asked if the PDC information can be downloaded
within the preview website.
Because the data are not yet publicly reported
and this is intended only to be a preview of the data,
you can not 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 shown
depending on which information was selected
for public reporting.
For clinicians, the possible files
are the "Clinician Performance Database", and the "Final Score
in 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's targeted for public reporting,
but was not selected for profile pages.
The "Final Score in Performance Category Scores Database"
contains MIPS final scores
and performance category scores for clinicians.
Groups may also have up to two files:
The "Group Performance Database"
and the "Patient Experience Database".
Similar to clinicians, 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 were not selected for profile pages.
CAHPS for MIPS scores
are in the "Patient Experiences Database."
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 the 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 scores
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, mentions 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 that the decision to opt out
of public reporting of performance information
is final for that year performance.
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.
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.
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 it 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.
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.
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.
And that 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 support team 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 this 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 this work together.