MVP ID: M1366
Most applicable medical specialty(s):
Gynecology, Obstetrics, Urogynecology, Nonphysician Practitioners, Certified Nurse Mid-Wives, Nurse Practitioners, Physician Assistants
Focusing on Women’s Health MVP focuses on the clinical theme of providing treatment and management of women’s health.
Quality
Report 4 quality measures (one must be an outcome or a high priority measure):
- Quality ID: 048: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older - MIPS CQMs
- Quality ID: 112: Breast Cancer Screening - eCQMs, MIPS CQMs, Medicare Part B claims measures
- Quality ID: 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan - eCQMs, MIPS CQMs, Medicare Part B claims measures
- Quality ID: 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention - eCQMs, MIPS CQMs, Medicare Part B claims measures
- Quality ID: 309: Cervical Cancer Screening - eCQMs
- Quality ID: 310: Chlamydia Screening for Women - eCQMs
- Quality ID: 335: Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse) - MIPS CQMs
- Quality ID: 336: Maternity Care: Postpartum Follow-up and Care Coordination - MIPS CQMs
- Quality ID: 400: One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation - MIPS CQMs
- Quality ID: 422: Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury - MIPS CQMs, Medicare Part B claims measures
- Quality ID: 431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling - MIPS CQMs
- Quality ID: 432: Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair - MIPS CQMs
- Quality ID: 448: Appropriate Workup Prior to Endometrial Ablation - MIPS CQMs
- Quality ID: 472: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture - eCQMs
- Quality ID: 475: HIV Screening - eCQMs
- Quality ID: 487: Screening for Social Drivers of Health - MIPS CQMs
- Quality ID: 493: Adult Immunization Status - MIPS CQMs
- Quality ID: 496: Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument - MIPS CQMs
- Quality ID: UREQA8: Vitamin D level: Effective Control of Low Bone Mass/Osteopenia and Osteoporosis: Therapeutic Level Of 25 OH Vitamin D Level Achieved - QCDR
Improvement Activities
Report Two medium-weighted improvement activities or One high- weighted improvement activity:
- IA_AHE_1: Enhance Engagement of Medicaid and Other Underserved Populations - High
- IA_AHE_12: Practice Improvements that Engage Community Resources to Address Drivers of Health - High
- IA_AHE_3: Promote Use of Patient-Reported Outcome Tools - High
- IA_AHE_9: Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols - Medium
- IA_BE_16: Promote Self-management in Usual Care - Medium
- IA_BE_4: Engagement of patients through implementation of improvements in patient portal - Medium
- IA_BMH_11: Implementation of a Trauma-Informed Care (TIC) Approach to Clinical Practice - Medium
- IA_BMH_14: Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women - High
- IA_CC_9: Implementation of practices/processes for developing regular individual care plans - Medium
- IA_EPA_2: Use of telehealth services that expand practice access - Medium
- IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways - High
- IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
- IA_PM_23: Use of Computable Guidelines and Clinical Decision Support to Improve Adherence for Cervical Cancer Screening and Management Guidelines - High
- IA_PM_6: Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities - Medium
Cost
Calculated by CMS using administrative claims data:
- Measure ID: MSPB_1: Medicare Spending Per Beneficiary (MSPB) Clinician
- Measure ID: TPCC_1: Total Per Capita Cost (TPCC)
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.