The Advancing Care Information (ACI) component of the Merit-Based Incentive Payment System (MIPS) is one of four performance categories under which MIPS eligible clinicians, including psychiatrists, will be scored as Medicare transitions to new quality and payment reforms. The ACI category is intended to replace the existing Medicare Electronic Health Record (EHR) Incentive Program known as "Meaningful Use," beginning in reporting year 2017 for reimbursement purposes in 2019.
How Much Does ACI Count in My MIPS Score?
The ACI category accounts for 25% of your total MIPS composite score. Your score for 2017 determines whether your Medicare Part B payments (in 2019) are subject to a positive, negative, or neutral adjustment. If, in the future, 75% of all MIPS eligible clinicians become successful reporters in this category (i.e., "meaningful users" of EHR technology), then the weight of the ACI category could be reduced to as low as 15% of the MIPS composite score.
How Does ACI Compare to the Meaningful Use (MU) Program?
The MIPS ACI category utilizes many of the same reporting objectives and measures that were used for the MU program. However, the new reporting requirements under ACI will offer psychiatrists some additional flexibility from the previous MU standards.
- For example, in Meaningful Use, every objective was to be reported and weighed equally for reimbursement purposes. Under the ACI category, psychiatrists have greater flexibility to choose which categories they wish to emphasize in their scoring.
- Also, the Meaningful Use program required that eligible clinicians attain certain reporting "thresholds" aligned with certain measures, whereas the ACI category allows eligible clinicians to align their reporting with their practice and experience.
- Finally, measurement in the ACI category emphasizes measures aligned with patient engagement and EHR interoperability compared to MU’s emphasis on process, which is evident in the elimination of the Meaningful Use Clinical Provider Order Entry and Clinical Decision Support objectives from the MIPS ACI reporting requirements.
What Do I Need to Do to Prepare for Reporting on the ACI category under MIPS?
As with the MU program, the ACI category requires psychiatrists and other eligible clinicians to use Certified Electronic Health Record Technology (CEHRT), as defined by the Office of the National Coordinator for Health Information Technology (ONC).
Can I Apply for a Hardship for this Category, as with the MU Program, if I Do Not Have Certified EHR Technology?
It is important for psychiatrists to understand that the failure to use CEHRT will result in receiving a score of zero for the MIPS ACI category. However, there are certain, very limited hardships for which an eligible clinician may apply, so that their performance in the ACI category is "weighted to zero," so it is not counted in their MIPS composite score.
These hardships include:
- Insufficient Internet Connectivity: The psychiatrist or eligible clinician must show they lacked “sufficient internet access, during the performance period, and that there would be insurmountable barriers to obtaining such infrastructure, such as a high cost of extending internet infrastructure to their facility.”
- Extreme and Uncontrollable Circumstances: These would include extreme circumstances, such as “a natural disaster in which an EHR or practice building are destroyed.”
- Lack of Control over Availability of CEHRT: This is for clinicians who practice at multiple locations or in practices where they cannot control the selection of health information technology. For example, this could include physicians who treat patients in several nursing home facilities. The patients seen at multiple locations must account for at least half of that clinician’s patients.
- Lack of Face-to-Face Patient Interaction: This is designed for clinicians whose work during the performance period did not involve seeing patients face-to-face, such as pathologists and radiologists. Telepsychiatry and other forms of telehealth are considered “face-to-face.”
CMS will be releasing a draft of the hardship application with more information. Applications can be submitted on a rolling basis, but must be received by the close of the submission period for the relevant performance year (e.g., for the 2017 performance period, applications must be submitted no later than March 31, 2018), unless CMS specifies a later date. A new application must be submitted each year.
Advancing Care Information: Reporting
What Are the Reporting Requirements Under ACI?
The ACI category requires that psychiatrists and other eligible clinicians report on six objectives and their associated measures, as indicated in the table below.
- These objectives and measures are aligned with the Office of the National Coordinator for Health IT (ONC) 2015 standards for Certified Electronic Health Record Technology (CEHRT).
- 2017 is a transition year for the new MIPS program, and some clinicians may still be using CEHRT tied to the 2014 ONC standards. Therefore, CMS is allowing for eligible clinicians to use their 2014 CEHRT, but with slightly different measure requirements for reporting purposes. These are referred to as the “Advancing Care Information Transition Objectives and Measures,” and values aligned with these measures can be explored on CMS’ Quality Payment Program’s ACI Measures Selection Tool.
Advancing Care Information: Scoring
How Is the ACI Category Scored?
ACI is broken down into two scores: a Base Score and a Performance Score which, when added together, result in a potential maximum score of 100 points for the ACI category. (It is actually possible to earn more than 100 total points, as explained below.) There are multiple ways by which psychiatrists can achieve a score of 100 points, which depend largely on choosing to report measures that are best reflected in your practice. However, it should be noted that failure to achieve at least a Base Score will result in a total ACI score of zero.
How is the ACI "Base Score" Calculated?
The Base Score accounts for 50 possible points of the total ACI category score. These 50 points are derived from reporting on five specific measures under ACI. For the Base Score, a psychiatrists or other clinician must report either Yes/No or a Numerator/Denominator for the required subset of measures. The measure requiring a “Yes” answer for the Base Score is the Security Risk Analysis measure under the Protect Patient Health Information Objective. Other measures that require reporting at least a numerator of “1” for the base score are: e-Prescribing, Provide Patient Access, Send Summary of Care, and Request/Accept Summary of Care.
What is a “Security Risk Analysis”?
The Security Risk Analysis (SRA) measure is similar to the HIPAA requirement that clinicians conduct “an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of e-PHI held by the organization . . . this includes all e-PHI an organization creates, receives, maintains, or transmits. All forms of electronic media, such as hard drives, floppy disks, CDs, DVDs, smart cards, or other storage devices, personal digital assistants, transmission media, or portable electronic media.” See Appendix I: Resources below, on conducting a Security Risk Analysis.
How is the “Performance Score” Calculated?
Once a psychiatrist earns the required 50 points for the Base Score, he or she can earn additional points in the Performance Score. The Performance Score is based upon performance on measures falling under three objectives: Patient Electronic Access, Coordination of Care Through Patient Engagement, and Health Information Exchange objectives. There are eight measures that fall within these three objectives. Each measure is worth up to 10 possible percentage points. Thus, a psychiatrist can potentially earn a Performance Score of up to 80 potential points. Only 50 Performance Score points are needed, to add to the 50 Base Score points, to achieve the 100 total points needed for full credit in the MIPS ACI category.
What are “Bonus Points” under ACI?
Psychiatrists who earn the full 50 points needed for a Base Score may also be able to earn bonus points, under the Performance Score. Bonus points can be earned in a couple of different ways.
- The first way is to report on one or more of the measures under the objective, Public Health and Clinical Data Registry Reporting (other than the Immunization Registry Reporting Measure). Up to a five percent bonus may be awarded for reporting (Yes/No) on these measures.
- A second way to earn bonus points under the ACI category is to use CEHRT for reporting certain MIPS Improvement Activities. The psychiatrist or other clinician must attest to having completed at least one or more of these activities for up-to a potential 10 percent bonus. These activities are listed in Appendix II, below.
Appendix I: Security Risk Analysis Resources
- The ONC/Office of Civil Rights/HHS Office of the General Counsel Security Risk Assessment (SRA) Tool
- The ONC Security Risk Assessment (SRA) Video
- Centers for Medicare and Medicare Services (CMS) Security Risk Analysis Tipsheet: Protecting Patients’ Health Information
Appendix II: MIPS Performance Improvement Activities Captured By CEHRT/Eligible For ACI Bonus
- Provide 24/7 access to eligible clinicians or groups who have real-time access to patient’s medical record
- Anticoagulant management improvements
- Glycemic management services
- Chronic care and preventative care management for empaneled patients
- Implementation of methodologies for improvements in longitudinal care management for high risk patients
- Implementation of episodic care management practice improvements
- Implementation of medication management practice improvements
- Implementation or use of specialist reports back to referring clinician or group
- Implementation or documentation improvements for practice/process
- Implementation of practices/processes for developing regular individual care plans
- Practice improvements for bilateral exchange of patient information
- Use of certified EHR to capture patient reported outcomes
- Engagement of patients through implementation of improvements
- Engagement of patients, family, and caregivers in developing a plan of care
- Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs
- Leveraging a QCDR [qualified clinical data registry] to standardize processes for screening
- Implementation of integrated PCBH [patient-centered behavioral health] model
- Electronic Health Record Enhancements for BH [behavioral health] data capture
What should I do if I have questions or issues regarding Medicare quality and payment reform?
APA members can submit questions by email to APA staff at email@example.com.
What other resources are available?