Easier MIPS—Better Care, Higher Scores

March 19, 2018

Doctors reviewing MIPS

CMS Wants to Know…

Since MACRA first went into effect, placing reporting pressure on Medicare providers, CMS has continued to analyze the burden on clinicians.  Modern Healthcare published a web article on February 23, 2018, called CMS Looks to Study MIPS Burdens on Clinicians. In the article, a new CMS survey is seeking clinician input on the burdens associated with reporting quality measures for the Merit-based Incentive Payment System (MIPS). Completing the survey awards full credit for the MIPS Improvement Activities category, which is weighted 15% for 2018.  CMS is accepting applications through March 23, 2018, so act now!

The survey’s stated goals are:

  • Study clinical workflows and data collection methods using different submission systems
  • Understand the challenges you have when you collect and report quality data
  • Recommend changes to try to lower your burden, improve quality data collection and reporting, and enhance clinical care

One of the primary aims of the Quality Payment Program is to decrease the burden of participation.  Quality reporting can be extremely labor intensive, but it doesn’t have to be.  Third-party intermediaries, like QCDRs, can help.

Do you utilize a Qualified Clinical Data Registry (QCDR) for MIPS? If so, learn about several 2018 Improvement Activities that leverage a QCDR, listed at the end of this article.

Unburden yourself

MIPS reporting may indeed present challenges. But what if you had a MIPS solution, today, with an easier workflow that included these features:

  • Automated data collection and continuous measure monitoring so you can close care gaps and make targeted improvements throughout the year before submission

SPH's MIPS Dashboard

  • Expert guidance on quality measure selection, performance optimization, and understanding necessary data elements for success
  • An intuitive dashboard of multi-payer measure performance across Medicare and non-Medicare patients to support all payer quality improvement initiatives
  • Provider performance comparisons for organizational quality assessment
  • Guided, automated MIPS submissions to CMS for group or individual level performance data for all MIPS categories

The benefits of a smart MIPS application include reduced administrative burden, data visibility across a network, improved measure performance and a higher MIPS composite score for positive adjustments. Scoring above 70 points (the exceptional performance threshold for 2018) could be well within reach.

The SPH Analytics Quality Measures Medicare module is for individual providers and groups participating in the MIPS or an Alternative Payment Model (APM). Clinical data across all payers can be aggregated and normalized across multiple EHR systems and used to calculate clinical quality measures.

Learn more

SPH Analytics Population Care Quality Measures


Helping providers gain visibility into their quality measure results throughout the year so proactive steps can help improve performance for CMS submission or commercial payer reporting.

CMS MIPS Reporting Burden Study

See also: Healthcare Finance, “CMS to clinicians: Help us better understand the burden of MIPS,” February 26, 2018, http://www.healthcarefinancenews.com/news/cms-clinicians-help-better-understand-burden-mips.

2018 QCDR-related Improvement Activities


  • Use of QCDR for feedback reports that incorporate population health (IA_PM_7)
  • Use of QCDR data for quality improvement such as comparative analysis reports across patient populations (IA_PM_10)
  • Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination (IA_CC_6)
  • Use of QCDR to support clinical decision making (IA_BE_2)
  • Participation in a QCDR, that promotes use of patient engagement tools (IA_BE_7)
  • Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement (IA_BE_9)


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