Patient Safety and Support of Positive Experiences with Anesthesia MVP (ID G0059)

Beginning with the 2023 Performance Period

Quality

Report 4 quality measures (one must be an outcome or a high priority measure):

• #404: Anesthesiology Smoking Abstinence (MIPS CQMs Specifications) (!!)
• #424: Perioperative Temperature Management (MIPS CQMs Specifications) (!!)
• #430: Prevention of Post-Operative Nausea and Vomiting (PONY) - Combination Therapy (MIPS CQMs Specifications) (!)
• #463: Prevention of Post-Operative Vomiting (POV)- Combination Therapy (Pediatrics) (MIPS CQMs Specifications) (!)
• #477: Multimodal Pain Management (MIPS CQMs Specifications) (!)
• AQI48: Patient-Reported Experience with Anesthesia (QCDR) (!!)
• AQI69: Intraoperative Antibiotic Redosing (QCDR) (!)

Improvement Activities

Report Two medium-weighted improvement activities or One high- weighted improvement activity:

• IA_BE_6: Regularly Assess Patient Experience of Care and Follow Up on Findings (High)
• IA_BE_22: Improved practices that engage patients previsit (Medium)
• IA_BMH_2: Tobacco use (Medium)
• IA_CC_2: Implementation of improvements that contribute to more timely communication oftest results (Medium)
• IA_CC_15: PSH Care Coordination (High)
• IA_CC_19: Tracking of clinician's relationship to and responsibility for a patient by reporting MACRA patient relationship codes (High)
• IA_EPA_1: Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Records (High)
• IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
• IA_PSPA_1: Participation in an AHRQ-listed patient safety organization (Medium)
• IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements (Medium)
• IA_PSPA_16: Use of decision support and standardized treatment protocols (Medium)

Cost

Calculated by CMS using administrative claims data:

• 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 (POMP) (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

Notes:

• Quality measures that are considered high priority are identified with an exclamation point (!)
• Outcome measures are identified with a double exclamation point (!!)

MVP Registration

• MVP Participants must register between April 1 – November 30, 2023 to report an MVP in 2023.
• 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 (November 30, 2023).
  • Report on an MVP they didn’t register for during the 2023 performance year.
  • Report on more than one MVP.
• The 2023 MVP Registration Form can be found at this link.