MVP ID: M0002
Most applicable medical specialty(s):
Nephrology
The Optimal Care for Kidney Health MVP focuses on the clinical theme of providing fundamental treatment and management of costly clinical conditions that contribute to, or may result from, kidney disease.
Quality
- Quality ID: 001: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) - Intermediate Outcome, High Priority, eCQMs, MIPS CQMs, Medicare Part B claims measures
- Quality ID: 047: Advance Care Plan - Process, High Priority, MIPS CQMs, Medicare Part B claims measures
- Quality ID: 130: Documentation of Current Medications in the Medical Record - Process, High Priority, eCQMs, MIPS CQMs
- Quality ID: 236: Controlling High Blood Pressure - Intermediate Outcome, High Priority, eCQMs, MIPS CQMs, Medicare Part B claims measures
- Quality ID: 482: Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate - Intermediate Outcome, High Priority, MIPS CQMs
- Quality ID: 487: Screening for Social Drivers of Health - Process, High Priority, MIPS CQMs
- Quality ID: 488: Kidney Health Evaluation for Patients with Diabetes - Process, eCQMs, MIPS CQMs
- Quality ID: 489: Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Process, MIPS CQMs
- Quality ID: 493: Adult Immunization Status - Process, MIPS CQMs
- Quality ID: 503: Gains in Patient Activation Measure (PAM) Scores at 12 Months - Patient Reported Outcome, High Priority, MIPS CQMs
Improvement Activities
Report Two medium-weighted improvement activities or One high- weighted improvement activity:
- 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_14: Engage Patients and Families to Guide Improvement in the System of Care - High
- IA_BE_15: Engagement of Patients, Family, and Caregivers in Developing a Plan of Care - 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_BE_6: Regularly Assess Patient Experience of Care and Follow Up on Findings - High
- IA_CC_13: Practice Improvements to Align with OpenNotes Principles - Medium
- IA_CC_2: Implementation of improvements that contribute to more timely communication of test results - Medium
- IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways - High
- IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
- IA_PM_11: Regular review practices in place on targeted patient population needs - Medium
- IA_PM_13: Chronic Care and Preventative Care Management for Empaneled Patients - Medium
- IA_PM_16: Implementation of medication management practice improvements - Medium
- 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 - Medium
Cost
Calculated by CMS using administrative claims data:
- Measure ID: COST_AKID_1 Acute Kidney Injury Requiring New Inpatient Dialysis
- 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.