MVP ID: M1369
Most applicable medical specialty(s):
Mental Health, Behavioral Health, Psychiatry
The Quality Care in Mental Health and Substance Use Disorders MVP focuses on the clinical theme of promoting prevention of and quality care in behavioral health, including mental health and substance use disorders (SUD).
Quality
Report 4 quality measures (one must be an outcome or a high priority measure):
- Quality ID: 009: Anti-Depressant Medication Management - Process, eCQMs
- Quality ID: 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan - Process, eCQMs, MIPS CQMs, Medicare Part B claims measures
- Quality ID: 305: Initiation and Engagement of Substance Use Disorder Treatment - Process, High Priority, eCQMs
- Quality ID: 366: Follow-Up Care for Children Prescribed ADHD Medication (ADD) - Process, eCQMs
- Quality ID: 370: Depression Remission at Twelve Months - Outcome, High Priority, eCQMs, MIPS CQMs
- Quality ID: 382: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment - Process, High Priority, eCQMs
- Quality ID: 383: Adherence to Antipsychotic Medications For Individuals with Schizophrenia - Intermediate Outcome, High Priority, MIPS CQMs
- Quality ID: 468: Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) - Process, High Priority, MIPS CQMs
- Quality ID: 487: Screening for Social Drivers of Health - Process, High Priority, MIPS CQMs
- Quality ID: 502: Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder - Patient Reported Outcome, High Priority, MIPS CQMs
- Quality ID: 504: Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk - Process, High Priority, MIPS CQMs
- Quality ID: 505: Reduction in Suicidal Ideation or Behavior Symptoms - Patient Reported Outcome, High Priority, MIPS CQMs
- Quality ID: MBHR2: Anxiety Response at 6-months - Patient Reported Outcome, High Priority, QCDR
- Quality ID: MBHR7: Posttraumatic Stress Disorder (PTSD) Outcome Assessment for Adults and Children - Patient Reported Outcome, High Priority, 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_5: MIPS Eligible Clinician Leadership in Clinical Trials or CBPR - Medium
- IA_AHE_9: Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols - Medium
- IA_BE_12: Use evidence-based decision aids to support shared decision-making - Medium
- IA_BE_16: Promote Self-management in Usual Care - Medium
- IA_BE_23: Integration of patient coaching practices between visits - Medium
- IA_BMH_14: Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women - High
- IA_BMH_15: Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults - High
- IA_BMH_2: Tobacco use - Medium
- IA_BMH_5: MDD prevention and treatment interventions - Medium
- IA_BMH_7: Implementation of Integrated Patient Centered Behavioral Health Model - High
- 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_6: Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities - Medium
- IA_PSPA_32: Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support - High
Cost
Calculated by CMS using administrative claims data:
- Measure ID: COST_DEP_1: Depression
- Measure ID: COST_PRC_1: Psychoses and Related Conditions
- Measure ID: MSPB_1: Medicare Spending Per Beneficiary (MSPB) Clinician
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.