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TCPI July 24 Update: VCSQI Bi-weekly Newsletter

Your Data is Past Due: TCPI Measures Data for April 1–June 30 is needed ASAP to VCSQI

Q2 2018 data for your selected TCPI quality metrics are due to Eddie Fonner ASAP to meet our analysis and TCPI submission deadline of July 31.  Please contact Eddie, Rick Koss, Ivan Berkel or Sherri White if you have questions about how to submit this data.  It is aggregate data (numerators and denominators) for your selected measures, NOT patient-level data.


Very Important 2018 MIPS Note: If you’ve not yet selected and started collecting data for 2018 MIPS reports, please contact Debbie, Ivan, or Eddie for assistance. We’re here to help!



A CHANGE for JULY 26th Webinar: We’ll Focus on 3 Milestones related to Quality Improvement

This Thursday we are changing the topic from Opioid Management Workgroup (OMW) to a review of 3 milestones that several practices are still working through (see below).  Debbie, Ivan and Sherri will share some tools and strategies, and invite you to engage in discussion with questions, comments and suggestions for each other.  Debbie will send a calendar correction of the topic to all primary contact persons for our participating practices.


  • #14 (19 on primary care) – Practice uses an organized approach (e.g. use of PDSAs, Model for Improvement, Lean, FMEA, Six Sigma) to identify and act on improvement opportunities.
  • #15 (20 on primary care) – Practice builds QI capability in the practice and empowers staff to innovate and improve.
  • #16 (21 on primary care) – Practice regularly produces and shares reports on performance at both the organization and provider/care team level, including progress over time and how performance compares to goals. Practice has a system in place to assure follow up action where appropriate.




Now Available: MIPS 2017 Performance Feedback User Guide

CMS has posted the 2017 Performance Feedback User Guide on CMS.gov to help eligible clinicians and groups understand their 2017 Merit-based Incentive Payment System (MIPS) performance feedback.  CMS also recently posted its 2017 Performance Feedback Fact Sheet, which offers an overview of what performance feedback is, who receives the feedback, and how to access it on the Quality Payment Program website.


Some incorrect scores have been noted by our participating practices and CMS has advised us that this is a known issue that is in the process of being corrected. If not resolved to your satisfaction, you should request a “Targeted Review” to correct your data scores.



The Deadline for Submitting a MIPS Targeted Review Request Is Now October 1, 2018

If you participated in the Merit-based Incentive Payment System (MIPS) in 2017, your MIPS final score and performance feedback is now available for review on the Quality Payment Program website. The payment adjustment you will receive in 2019 is based on this final score. MIPS eligible clinicians or groups (along with their designated support staff or authorized third-party intermediary), including those who are subject to the APM scoring standard may request for CMS to review their performance feedback and final score through a targeted review.



When to Request a Targeted Review:  If you believe an error has been made in your 2019 MIPS payment adjustment calculation, you can request a targeted review until October 1, 2018.  For more information about how to request a targeted review, please refer to the Targeted Review of the 2019 Merit-based Incentive Payment System Payment Adjustment Fact Sheetand the Targeted Review of 2019 MIPS Payment Adjustment User Guide.


CMS to Offer Targeted Review Q&A Sessions- Sign Up Below


Webinars on MIPS Performance Categories for Year 2 (2018) Presented by CMS

The webinars will provide an overview on the Cost, Improvement Activities, and Quality performance categories. Subject matter experts will cover topics including category requirements, scoring details, and data submission mechanisms.


Requests for Small Practice Hardship Exclusion from Promoting Interoperability Category

Small practices can request a hardship exclusion from the Promoting Interoperability category. Request is due by end of year but you should apply sooner to be safe! Your percent for the Promoting Interoperability Category gets moved to the Quality Category. Here is the link to learn more and apply: https://qpp.cms.gov/about/small-underserved-rural-practices



Predict MIPS Future Success with 2018 MIPS Estimator

With the first year of MIPS participation now complete, clinicians continue to need tools and assistance to reduce the burden of understanding and meeting MIPS requirements and preparing for value-based care.  The Stratis Health 2018 MIPS Estimator is now available at no charge.  See changes in the MIPS program and identify whether you qualify for bonus points or performance improvement points.


Note of Interest:  TCPI is designated an APM under the Quality Payment Program


Participation in TCPI can only result in a higher overall MIPS score; it will never result in a lower score.  It is not considered an Advanced APM, nor a MIPS APM. This APM designation provides partial scoring credit toward the MIPS Improvement Activities performance category for those MIPS eligible clinicians participating in TCPI. This assignment rewards MIPS eligible clinicians for implementing clinical practice improvement by participating in the model. Participation in TCPI does not exempt participants from MIPS, nor does it modify reporting requirements under MIPS. It also does not change the scoring requirements, as participants are scored in the same manner as other MIPS eligible clinicians. Rather, the only impact is that participating MIPS eligible clinicians automatically receive at least partial credit in the Improvement Activities performance category.



Sharing New PFE Resources:


 Upcoming VCSQI 2.0 Workgroups:
  • This week’s Workgroup changed to Quality Improvement Milestone Discussion— July 26, 1-2 pm
  • Next PFE Workgroup August 8, 1-2 pm



Did You Hear? CMS Proposes Historic Changes to Modernize Medicare and Restore the Doctor-Patient Relationship 

On July 12, CMS proposed changes to increase time doctors and clinicians can spend with patients by reducing the burden of paperwork when billing Medicare. Check out www.davidyorkstaxservice.com/. The proposed rule allows clinicians to use their Electronic Health Records (EHRs) to document clinically meaningful information, instead of information that is only for billing purposes.  More info to come when available.



Quote to Ponder:

“Enough is enough. CMS’s focus is on putting patients first, and that means protecting the doctor-patient relationship. We believe that you should be able to focus on delivering care to patients, not sitting in front of a computer screen.” – Seema Verma, Administrator, CMS Department of Health & Human Services

Link to full letterDear Doc Letter final 7-16-18



Visit the VCSQI website and see more resources and information in the sidebar of tabs on the right. 


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