MVP ID: M0001
Most applicable medical specialty(s):
Oncology, Hematology
The Advancing Cancer Care MVP focuses on the clinical theme of providing fundamental treatment and management of cancer care. The measures assess three critical areas: the patient experience of care, end of life care, and appropriate diagnostics along with possible treatment options for different cancer diagnoses.
Quality
Report 4 quality measures (one must be an outcome or a high priority measure):
- Quality ID: 047 - Advance Care Plan
- Quality ID: 134 - Preventive Care and Screening: Screening for Depression and Follow-Up Plan
- Quality ID: 143 - Oncology: Medical and Radiation - Pain Intensity Quantified
- Quality ID: 144 - Oncology: Medical and Radiation - Plan of Care for Pain
- Quality ID: 321 - CAHPS for MIPS Clinician/Group Survey
- Quality ID: 450 - Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer
- Quality ID: 451 - RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy
- Quality ID: 452 - Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies
- Quality ID: 453 - Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life
- Quality ID: 457 - Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days
- Quality ID: 462 - Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy
- Quality ID: 487 - Screening for Social Drivers of Health
- Quality ID: 490 - Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors
- Quality ID: 503 - Gains in Patient Activation Measure (PAM) Scores at 12 Months
- Quality ID: PIMSH13 - Oncology: Mutation Testing for Stage IV Lung Cancer Completed Prior to the Start of Targeted Therapy
- Quality ID: PIMSH2 - Oncology: Utilization of GCSF in Metastatic Colorectal Cancer
Improvement Activities
Report Two medium-weighted improvement activities or One high- weighted improvement activity:
- Activity ID: IA_BE_15 - Engagement of Patients, Family, and Caregivers in Developing a Plan of Care
- Activity ID: IA_BE_24 - Financial Navigation Program
- Activity ID: IA_BE_4 - Engagement of patients through implementation of improvements in patient portal
- Activity ID: IA_BE_6 - Regularly Assess Patient Experience of Care and Follow Up on Findings
- Activity ID: IA_BMH_12 - Promoting Clinician Well-Being
- Activity ID: IA_CC_1 - Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop
- Activity ID: IA_CC_13 - Practice Improvements to Align with OpenNotes Principles
- Activity ID: IA_CC_17 - Patient Navigator Program
- Activity ID: IA_EPA_1 - Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record
- Activity ID: IA_EPA_2 - Use of telehealth services that expand practice access
- Activity ID: IA_ERP_4 - Implementation of a Personal Protective Equipment (PPE) Plan
- Activity ID: IA_MVP - Practice-Wide Quality Improvement in MIPS Value Pathways
- Activity ID: IA_PCMH - Electronic submission of Patient Centered Medical Home accreditation
- Activity ID: IA_PM_14 - Implementation of methodologies for improvements in longitudinal care management for high risk patients
- Activity ID: IA_PM_15 - Implementation of episodic care management practice improvements
- Activity ID: IA_PM_16 - Implementation of medication management practice improvements
- Activity ID: IA_PM_21 - Advance Care Planning
- Activity ID: IA_PSPA_13 - Participation in Joint Commission Evaluation Initiative
- Activity ID: IA_PSPA_16 - Use decision support—ideally platform-agnostic, interoperable clinical decision support (CDS) tools —and standardized treatment protocols to manage workflow on the care team to meet patient needs.
- Activity ID: IA_PSPA_28 - Completion of an Accredited Safety or Quality Improvement Program
Cost
Calculated by CMS using administrative claims data:
Population Health Measures
Select one population health measure to be scored by CMS using administrative claims data:
- #479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Program (MIPS) Groups (Administrative Claims)(!!)
- #484: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (Administrative Claims) (!!)
Promoting Interoperability
Report on the same PI measures required under traditional MIPS unless qualified for automatic reweighting or approved hardship exception:
- Prevention of Information Blocking
- e-Prescribing
- Query of the Prescription Drug Monitoring Program (PDMP) (Optional)
- Provide Patients Electronic Access to Their Health Information
- Support Electronic Referral Loops By Sending Health Information AND
- Support Electronic Referral Loops By Receiving and Reconciling Health Information OR
- Health Information Exchange (HIE) Bi-Directional Exchange
- Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA)
- Immunization Registry Reporting
- Syndromic Surveillance Reporting
- Electronic Case Reporting
- Public Health Registry Reporting
- Clinical Data Registry Reporting
- Security Risk Analysis
- Safety Assurance Factors for EHR Resilience Guide (SAFER Guide)
- ONC Direct Review
MVP Registration
- MVP Participants must register between April 1 – December 2, 2024 to report an MVP in 2024.
- To register, MVP Participants must select:
- The MVP they intend to report.
- 1 population health measure included in the MVP.
- Any outcomes-based administrative claims measures on which the MVP Participant intends to be scored (if available).
- If reporting as a subgroup, registration must also include:
- A list of Taxpayer Identification Numbers (TINs)/National Provider Identifiers (NPIs) in the subgroup;
- A plain language name for the subgroup (which will be used for public reporting);
- A description of the composition of the subgroup, which may be selected from a list or described in a narrative.
- MVP Participants won’t be able to:
- Submit/make changes to the MVP they select after the close of the registration period (December 2, 2024).
- Report on an MVP they didn’t register for during the 2024 performance year.
- Report on more than one MVP.