Okay, so welcome, this is our pre-recorded session for the AAPM&R meeting. This is the MIPS update for 2021, and this is regards to changes that are upcoming for 2021, as well as member perspectives on reporting. As far as disclosures, there are no disclosures by all the panelists, including Dr. Yang and Dr. Kwasnika. As far as objectives today, we're going to review the latest reporting requirements and performance categories for MIPS, and some of the proposed MIPS value pathways. We're also going to share experiences regarding MIPS reporting from small and solo practices, then finally discuss some of the current challenges that we face as a specialty. So now I'm going to hand it off to Bob Jasik from Heart Health Strategies. So what I'm going to do today is try and focus on just some of the new aspects of MIPS for reporting in 2021. We'll talk a little bit more about that program and just make sure that we're all on the same page. And we'll also talk about all of this, of course, in the context of the COVID-19 pandemic and what that means for your reporting requirements and potential flexibilities. As we're going through this information, it's just important to remember that the program changes by year. And so some of the things that we'll be used to from 2020 will not carry over to 2021. And also that goes for the COVID-19 flexibilities as well that we're going to talk about. So just make sure that as we go through, and I'll try and point this out, that you're paying close attention to the requirements for the year that we're talking about. Before we get into MIPS proper, I want to start with one of the elephants in the room. And that is the Medicare Physician Fee Schedule conversion factor for 2021. Just as a quick refresher to everybody on how Medicare payments are calculated, there are the RVUs for the code that you bill, of course. Those are multiplied by the conversion factor, and that's how you get your payment. And each year, the conversion factor is calculated based on a number of different factors, but there are two major ones. And one is any statutory updates that were put into law by Congress. And if you look over at the left of the slide, what you'll see are what those statutory updates were. So there were small bumps added to overall Medicare Physician Fee Schedule spending when we changed over to this whole new model starting in 2016, but those small bump ups ended in 2020 this year. There will not be another statutory bump up in 2021 either. If you look at the middle, though, that you can see that the conversion factor and the actual change in the conversion factor doesn't track with those percentages at the left. And that's because the conversion factor is also subject, the calculation of the conversion factor is also subject to a couple of other things. Primarily, one major way that it's calculated has to do with the budget neutrality requirements that are set in statute. And basically, the shorthand of that is that if Medicare changes its policies to increase spending, that it has to be done in a budget neutral way. So they reduce the current conversion factor to make sure that overall Medicare spending doesn't go up. And what you can see in 2021 is that there was a proposed reduction to the conversion factor of 10.61%. That doesn't mean that your payments will be cut by 10 or 11% because what's driving that cut in the conversion factor is an increase to the office and outpatient E&M codes. So when you're billing those, you'll see increases associated with those services. However, for the rest of your services that you bill that are not the office and outpatient E&M code set, they're only going to be multiplied by $32, as you can see there, which is significantly less than it is this year. That may change. Congress is getting involved, but I wanted to point that out. And I think the reason that it's important to start our conversation out about MIPS with that is that it just makes the importance of meeting the MIPS requirements or knowing what you need to do to get a neutral payment adjustment all the more important given the changes that are happening in the conversion factor. So I wanted to start out with that. But jumping into the MIPS program, which is what we're really here to talk about today. So in 2021, the conversion factor will be calculated. As I mentioned, there's the base update of zero, but that because of budget neutrality, there'll be a negative 10.6% reduction in the conversion factor. So you have your RVUs times the conversion factor, and then your payments will be updated by one of two ways. And that's either through the Merit-Based Incentive Payment System, MIPS, or you'll get a bonus for participating in an advanced alternative payment model. In the interest of time and keeping focus, we're going to focus today mostly on the Merit-Based Incentive Payment System, and that's because that's where most of you will find yourselves. The alternative payment model trajectory just hasn't taken off the way that a lot of people were hoping it would when this was first created. And so most people will still be in MIPS. That could change in future years. And if you're participating in a Medicare ACO, you may find yourselves on the APM side of the house, but most people are participating in MIPS. And so that's what we're going to focus on here. In order to find out whether you are included in MIPS or excluded in MIPS because you're participating in an alternative payment model or because you don't bill enough Medicare services, what you can do is you can go to this website, which you see at the top of the slide, and put in your NPI, and then you will look up what your status is in the program. And when you do that, this is what will come up. It will show you your status both as an individual and if you're a part of a group, it will tell you whether the group is required to report or excluded from reporting as a group. And the MIPS program is set up so that you can choose to participate either as a group or an individual. And so it's important to make sure that you know your status in either way, as an individual or a group. So that's the way you can look up and see just right off whether you're required to participate into MIPS and would be subject to the MIPS payment updates if you didn't. This is our quick overview of the merit-based incentive payment system. This is basically a score that you get based on your performance in four different performance categories, quality, cost, promoting interoperability, which is the new version of the old Meaningful Use Program, and then also your assessment of your participation in clinical improvement activities. If you look down at the bottom, you can see that across the timeline, this was all set in law, that the financial stakes of this program change as we've moved along the timeline. And just sort of two important things to note about that timeline that you see down at the bottom. First of all is that your payments are updated, premised on the reporting that you do two years prior. So if we're looking at 2020 in the dark green, your payments are being updated this year based on the reporting that you did or did not do in 2018. So when we're talking about 2020, I'm sorry, 2021 reporting, the lighter green, which is what we're going to talk about today, that's going to affect your payments in 2023. Also, if you look across the bottom, you can see the financial stakes, and they've grown. There are potential penalties of up to 9% now for not participating in this program. As far as the plus side, and this is going to become important later when we start talking about some of the flexibilities associated with the COVID public health emergency, is that the bonuses that are associated with participating in MIPS can only go up if money is collected based on penalties. So the fewer penalties there are, the less bonus money there is to put to the higher performers. And so when you see that plus 7%, plus 9%, just know that they haven't gone up that high, even though the penalties are that high, because a lot of people are meeting exclusions or otherwise not being subject to penalties. So there's not as much bonus money at the top end. So keep that in mind as we keep talking about this. And as you're thinking about sort of the cost benefit analysis of how much administrative burden and cost there is associated with this program versus the upside, or whether you want to, the goal is to just be basically held harmless and have a 0% MIPS update. Those four categories in the scoring methodology are not all created equally. And what you see over at the right are the new weights that are proposed for 2021. For quality, it's going to go from 45% down to 40%. And the cost category is going to go from 15% up to 20%. Those are the two areas where we're going to focus the most because of their impact on your final score. That doesn't mean that the Promoting Interoperability and Improvement Activity categories aren't important, but they haven't changed as much, and they don't have fluctuating weights right now. So we're going to focus on quality and cost. So with that, we'll jump right into the quality category. So for those of you that have already been participating in MIPS, you'll be familiar with this. But for others, MIPS just sets a general presumption that clinicians that are reporting to the program are going to be able to report on at least six quality measures. That being said, if you can't find six measures to report on, it's not an all-or-nothing program. So there's still a scoring benefit to reporting on as many measures as you can. As part of the base requirements of reporting, you also are required to report on an outcome or a high-priority measure if you don't have an outcome measure. And I'm going to show you some of these available measures and whether they're outcome or high-priority measures. And then for each measure, in order to get the maximum achievable points, you want to be scored on performance. You want to meet these base requirements. So the base requirements are over the course of 12 months, the calendar year. And for that measure, you need to be reporting on at least 20 patients to get access to the full score. And you have to pass what's called the data completeness threshold. And what that means is that you are reporting on at least 70% of the patients to which that measure applies. And that's going to be all patients, not just Medicare patients, if you are reporting via a registry, a QCDR, a quality clinical data registry, or via your EHR. And in 2021, there are a couple of safety net provisions in there. If you report, if you cross the data completeness threshold, but it doesn't result in reporting on at least 20 patients or there's no benchmark associated with that, you'll get at least three points. And then also, if you report on more than six measures, you don't have to feel like you have to pick and choose which ones you're going to do well on. If you report on more than that, Medicare is just going to take the scores associated with the measures that you score the best on. So there's not a gaming component in that fashion. Medicare also has what's called a specialty measure set for several specialties. And that includes physical medicine. What you see here is the list of measures that are on the physical medicine specialty measure set. Over at the left, you see whether those are outcome or high priority measures. So there is an incentive to report on those if you're able to. And then over at the right, you can see the reporting options that are available. But I would just note that for most practices, the claims option isn't available at all anymore because it's just for small groups. So a lot of registry measures that are available there, though. The other thing is in red, you will see the measures that have been removed from the physical medicine specialty measure set. This is just a suggested list. If you want to report on those or are able to report on those, you are still able to do that. But just note that they've been removed from the list here. And again, you don't have to report on all of these measures. It's just a list of suggested measures. Some of you who have gone through this exercise, though, depending on the site of service in which you practice, will likely find some of these measures difficult to report on. A lot of them are geared to the outpatient setting, and there aren't a lot of measures that are available in the inpatient setting via the traditional MIPS measure set. And that has proven to be a challenge for a lot of practices. And so I would add, one, again, that you report on as many measures as you can, but also, I want to note that the Academy has been developing measures because of this gap in available measures. And so I just wanted to put up here the screenshot of the registry website and how the AAPM&R has been designed to meet the quality reporting requirements of the programs that you see listed here. So you have the web address up at the top of the slide to look into that more if it's something that you're interested in and aren't doing already. But again, trying to find those measures that match your practice has been challenging, and the Academy is trying to address that need, which we'll hear more about later. So that's the quality category. One other thing that I would add is that there's also an option in the program called the facility-based scoring option. And facility-based, as you can see in the second major bullet there, are those clinicians who furnish more than 75% of their professional services in the inpatient hospital, on-campus outpatient hospital, or emergency department. And if you are one of those facility-based individuals, then you are eligible for scoring based on the hospital value-based purchasing program score that the hospital that you're attributed to gets. There's nothing you have to do to affirmatively choose this. It will be assigned to you if you've reported nothing else or if it's a more preferable score than you would get from the data that you submitted. So again, for some of those clinicians who may not have access to a large set of measures, it does not mean that you're automatically going to be penalized because you might be able to have a quality and cost score, even if you haven't submitted measures, if your hospital is doing their reporting in the hospital program side and they perform well so that you can get, hopefully, a positive payment update with that. So again, nothing affirmative you need to do, but know that that safety net is there. Switching to the cost performance category. As I had mentioned, there is an increase in the weighting of this category to 20%. That's expected to continue to grow based on statutory provisions that are in place unless they're changed. Here again, I would flag that there is no affirmative reporting obligation. You don't submit data to get a score in this category. It's all based off of administrative data. But I do want to mention one affirmative thing that you might want to consider. If you look at the box at the bottom, on your claims, you are able to append patient relationship codes to the CPT codes that you submit. And the reason that you see this here on the cost performance category slide is that those patient relationship codes will eventually be used to calculate your scores on cost measures. Right now, it is voluntary. It is also not going to impact those quality scores, but it might be something that you want to get used to doing to make sure that it's accurate for the day when it does impact your scores. And I would also add that under the improvement activities category that you can get credit for an improvement activity if you report these modifiers on claims for a continuous 90-day period. So that's something to consider here as you're looking to improve your overall MIPS score and also to try to get a handle on what your cost performance measures might look like in the future. Right now, the measures are primarily based on very large sort of clunky total cost of care measures, but the program has been introducing more episode-based cost measures. You can see a list of the episodes that were introduced here in 2019 that are still a part of the program, not largely applicable to PM&R, though. If you look at the episodes, though, that were introduced in 2020 that are still in effect for 2021, there's a lumbar spine fusion degenerative disease episode measure probably would not be attributed to you, but you may see facilities starting to pay more attention to the costs associated with that for the people who are being attributed that cost measure. So as these continue to develop and proliferate, you may see your cost score starting to shift to these types of episodes of care. In the interest of time, what we're going to do is just move to the last couple of summary comments here before I turn it over. The next couple of slides are just going to show you how all of this comes together from a scoring perspective. The reason that I wanted to show you your 2018 data is because this is the methodology that informs the payment updates that you are receiving now in calendar year 2020. So you can see that there were the four performance categories, but quality was weighted at 50% for the 2018 score, and if you look over at the table to the right, what that's translated to and your payment adjustments for this year are laid out there in sort of the tier. And if you look at the bottom, if you didn't report any data or got a very, very, very bad score, that means that on every single Medicare claim that you submit or your practice submits, there's a negative 5% penalty associated with it. And then as you move up the ladder, you can see there that in order to get a neutral payment adjustment, which is essentially a 0% adjustment, you had to get at least 15 points. And pay attention to that number as we move through the next couple of slides. So then your 2019 reporting has already basically set the course for what's going to happen to your payments next year in 2021. If you look down at the bottom, if you did nothing or your practice did nothing, then you're going to be subject to a negative 7% payment adjustment. And then you can also see in order to receive a neutral payment adjustment that you need at least 30 points. So we've gone from 15 to 30 points. So the requirements to break even on your MIPS score are starting to increase as time goes on. Then the reporting that you're doing this year that you're still submitting data on likely is you see the weights that are there. If you don't meet those reporting requirements or you don't qualify for something that gets you to the neutral payment adjustment level, you're subject to a negative 9% payment adjustment. Then you can again see that the neutral payment adjustment has gone from 30 points now to 45 points. So these requirements keep getting more intense. And then finally, since we're here to talk about what's happening next year, for 2021, your performance will be scored based on the four categories you see there with the weights that we've spoken about. And then if you look over at the right, again, if you don't do anything and you don't meet the reporting requirements or score poorly, you could be subject to a negative 9% penalty. And in order to receive a neutral payment adjustment, you need to get 50 points. Now for all of those positive payment adjustments that you see above that, I would just note it's not clear what the scale of those positive adjustments might be. And so you want to keep that in mind. And that's why I wanted to end here talking about all of this in the context of the COVID-19 public health emergency. So you've likely already seen a lot of the flexibilities that have been instituted by the agency, a lot of them having to do with provision of services via telehealth. And there have been some changes that have been made to the MIPS program in order to account for the environment that we find ourselves in. And I want to go back to one of the things that I started this conversation out with, which is it's very important when we're talking about this piece to make sure that you are very clearly categorizing which performance year it is that we're talking about. So a lot of the flexibilities that you have already heard about or potentially been eligible for have had to do with the scoring and the reporting for calendar year 2019. And that's the first column that you see there. So the reporting deadline for data for calendar year 2019 was March 31st of this year. And I don't need to tell anyone here that March, of course, was a very turbulent month. And one of the first things that the agency did was they extended that reporting deadline for 2019 data. So that reporting deadline was extended to April 30th of 2020. And then if you look at the second row, CMS created an automatic exemption because of the extenuating circumstances of COVID-19. And if you were an individual and only reporting as an individual and you weren't able to submit any data, then CMS is going to provide an automatic neutral payment adjustment when it comes time to calculate your payment adjustment for 2021. And I want you to take special note here that if you look across that row for this performance year that we're still in, for 2021 that we've been talking about during this session, there have been no accommodations made yet for an automatic adjustment like that. That could happen because the reporting deadline isn't until March of next year. But just note that even if you were eligible for that automatic exemption that you already received, that that doesn't exist yet for this reporting year. The third row is an application for that. So for those individuals who had submitted data and therefore didn't get the automatic exemption or for groups, since no groups got the automatic exemption, you were able to submit an application for 2019 to receive a neutral payment adjustment. And so for that application, COVID-19 was an approved use. And so most of those applications are expected to be approved. If you look at this year's performance year, the 2020 column, that application process is still open. So you have until December 31st of this year to apply for a neutral payment adjustment because of the COVID-19 public health emergency. And so that is still open and you want to consider that. But I will mention that note that you see there that if you submit MIPS data, that will override the hardship exemption. And then you'll be scored on whatever is submitted. So keep that in mind when you are mapping this out. And then you see two other flexibilities that are there that I would just add is that there's a COVID-19 improvement activity for 2020 that's been extended to 2021, which is for clinical data reporting with or without a clinical trial. And then also in the scoring methodology, there's a complex patient bonus for clinicians that are treating those patients. So with that, I'll wrap up here and turn it over. Just again, remember that MIPS isn't an all or nothing program. That being said, that the positive payment adjustments that are available to you are in question because of the COVID-19 flexibility. So the more people that avoid a penalty, the less bonus money there is. That may be okay. But I just want to mention that the plus side is not likely to be extensive. That 2020 extreme and uncontrollable circumstances application that I mentioned is open until December 31st, 2020. And you can see that application link there. And we'll have to wait to see what flexibilities are extended to 2021. But the other thing during the course of all of this is it might start to feel like this program is slowing down a little bit. Just remember that it's statutory and it's set in law. So when we are post-pandemic, just know that this program will still be in place because statute has set it there. And as we've talked about, those measures are going to change every year. The availability of alternative payment models is going to change. And so we just want to keep that in mind as we move along during the calendar years. So with that, thank you for tuning in. And I will turn it over now. So we're now going to talk about some of the member reporting experiences. So I wanted to first discuss the solo practice experience. And we're going to hear from Dr. Yang in that regard. About 18, 20 patients. And then I have kind of a side gig, all of some LTAC patients, a few times a week. Primarily IRF. Great. And then so how do you handle MITS reporting as a solo practitioner? So that's really been a big challenge. I've been doing it now on my, since I am by myself, I do it on my own. Fortunately, my billing company has a relationship with one of the companies that provides software I don't know if you want me to mention that or not, but I've been using the software company for the last two years. I'm using it again this year. I find the company to be fairly responsive to my needs. It's very easy to set up appointments for them to kind of, for me to describe my practice and they help me come up with measures. The first year was probably the most challenging because it was the most confusing. Last year was much easier. And I think this year is probably a little bit more challenging because things have changed a little bit again. So now when did you end up, I'm going to go off topic a little bit in terms of this MITS piece, but so when did you first start paying attention to MITS reporting? You mean the first year? Yeah. Well, like what year did you start thinking about reporting? Fortunately, I share an office with the medical director at my IRF and he's also a solo, but we're essentially as close as you can be to business partners without being in practice together. And one of the kind of unique advantages is he has an office manager and she does her research and I do my research with the company that I use and we kind of come together and we kind of realized we're mostly on the same page. The first year was definitely the hardest because we didn't really understand what measures. There was a lot of stress in terms of like, you know, it, it, it seems so complex and intimidating to identify the measures and how do you answer them? And it actually turned out actually wasn't that bad at all. You just had to kind of know as you work throughout the course of the year, okay, which patients might qualify for X, you know, six measures at the time. But luckily I had one guy to balance the ideas off of because I think without him, it would have probably been twice as hard, but that's probably the biggest challenge I had that first year. But it sounds like then just through, you know, almost listening to this sort of a colleague of yours, you're able to sort of together try and come up with your strategy. So like, how did you approach then? So how do you now approach miscompliance using this software program or this portal that you're using? Yeah. So, so my software is, you know, if you look at just the measures, I mean, I think that was probably the hardest thing is, you know, you just, you plop down, you see literally dozens and dozens of measures. You just don't even know. Most of them are just completely inapplicable to me. Right. And actually, especially in solo, inpatient PM&R, a lot of times what we do is a hybrid of, you know, a lot of different things. But my software, you know, I literally, I just, you know, you could just type in, OK, well, what E&M code? And so, for example, you know, 99232, like a moderate level initial exam. You could just type that in because you know that that's a big chunk of where they're looking to to get a measure is on the initial vow or follow up a vow. So you can just type in like the code that you use very commonly. And all of a sudden, instead of seeing, you know, oodles and oodles of measures, it really trims it down. And then from there, you can kind of get to see, OK, well, these are the types of patients I'll follow. These are not patients I follow. And then from there, it was actually fairly easy to kind of narrow it down. I just went for the fewest numbers of measures that I would need to to avoid the penalty. So did so did my my medical director for that. So it sounds like almost this software tool you used, you had a search function where you search by really your E&M code and then narrow down the ones you wanted to select. Correct, because I think initially before we kind of did that, we were just kind of looking at just kind of clinical applicability. And that was really, really hard because, you know, you start thinking, OK, well, you know, listen, this inpatient PM&R, you know, we're trying to do PM&R, but we all know that there's a little, depending on who we are, you know, some people have some comfort in medical management. I, for example, do, you know, do you really want to get into like, you know, you know, ACE inhibitors and the effect of X, Y and Z? And I felt like, OK, that's really I mean, I'll do it if someone needs to adjust medication. That's not what I'm about. And that was really not productive at all. And I think that's kind of why it was so intimidating at first. And then kind of the aha moment is like, OK, well, let's go the other way around. Let's look at, OK, eliminate. And all these other codes are so many outpatient codes. Fortunately, I could eliminate the vast majority of those. And that really narrowed it down quite a bit for me. So now, do you know, so which are the measures you're reporting on currently? Like, do you have a couple of examples? I mean, let me turn on my monitor because, let's see here, give me one second. I kind of have a feeling you'd ask me that. And so, by the way, the other challenge is that these measures change every year a little bit. So I'll just kind of list them off. I do a measure. So quality measures this year, number 47, which is an advanced care plan. Number 130, documentation of current meds in the medical record. Number 282, dementia functional status assessment within the last 12 months. 283, dementia associated behavioral screening and management. 291, Parkinson's cognitive impairment or dysfunctional assessment for patients with Parkinson's. And 342, which looks like that's a new one this year, pain brought under control within 48 hours. I mean, these are all, I mean, if you look at these, this is pretty easy for the most inpatient PMRs. You know, in the course of your population may differ. You know, you may be more trauma based or whatever. But, you know, I think at some point everyone's going to have someone with dementia, everyone's probably going to have someone with Parkinson's. The advanced care plan, the documentation, medical record, that's that's kind of all in there. So that's what I'm going with this year. And it's and I'll put a disclaimer on it. It's kind of so I'm entering my stuff as we speak. I know the year's not over, so I'm not waiting till the last minute. But I'm doing this as we speak. And I think I should be OK. I've been talking with my company two or three times in the last few weeks. So now with that, so how do you know what you're you know, what your performance is on those measures or like this? How does the tool give you the information on that? So, yeah, I mean, it's our our portal is actually pretty easy because as you enter everyone in, first of all, it'll if you try to enter something that's ineligible, for example, like I think there's certain measures that like if you're too old, the patient's too old, you know, you can't just I think with the advanced care plan, you can't put it in. It'll kind of make it ineligible. But as you enter stuff in, you'll have like a little counter that's going up. And, you know, my goal is to get at least a forty five this year. But once you hit a certain point, there's a little number that says, OK, well, you know, currently because I haven't had anything to do this year, I'm a minus nine. So I did nothing. I'm going to minus nine percent. But as it goes up, hopefully if I hit zero, then I think I'm good. And usually I'm going to stop at that point. Great. So and is this so is this tool mainly based on the quality piece, quality portion, then? So there's the quality. Yeah, there's the quality portion. But, you know, if I go back to my dashboard, there's the what is it called? The project promoting interoperability, which is so I'm I wanted to mention that I'm actually accepting that. Oh, probably because of the practice. Yeah. Yes. So that's actually allowed. We can get to that later, but I accepted from that. But there's that project and I'm completely blanking. Could be improvement activities. Yes. Improvement activity. So, you know, it's as I think, you know, for me, it's going to be a zero out of 15. But I kind of been looking at you sending a list. I'm kind of trying to figure out which one I want to do. And I think that doesn't look too hard. So I'll put that. And then down at the bottom, there's something called complex patient bonus. And in discussing with a comment, I'm not really sure. I mean, when it goes with that or we need to look for that. Yeah, that's good. So it sounds like the tool, you know, focuses mainly on the quality piece. But then, you know, the right there, that's a big portion. And then cost is a cost component. But obviously, there's really not much as much control we have over that. It's almost like that. So that's data already that basically CMS is going to have anyway. Yeah. So now I'm sorry. Go ahead. No, I was going to say there's, you know, with it, not to plug the company. And I mean, you said I didn't even really said what name it is. But they have several tiers. And so I went with a really basic tier because that's really all I needed. It can get it gets more expensive if you want to have. They have much, much more functionality. I've never even since I don't need. I don't know exactly what that includes. And right. And as a solo practitioner, you get a balanced cost of reporting versus and the time and effort for you and the resources do this versus, you know, let's you just need to do the minimum really to try and avoid the penalties. All right. You know, it's just a much higher bar to like try and go into a bonus area. Really. So so then what are some of the challenges you face with sort of this whole MIPS compliance from your standpoint? I think the biggest challenge is you really have to kind of stay on your toes. So I think the first year you finished it, you realize it wasn't that bad. You think, OK, well, this is just like, you know, I'll just do it every year. But then you realize, OK, things change. They don't change maybe that much, but they change. I think this year's changed more than last year. You know, and I think, you know, I don't know if they want to get into it, but I think on one of the measures, you have to try to report on at least 70 percent of the patients. Oh, yeah. And that's in. And that's where I have to work backwards with my billing company, say, OK, well, you know, hey, on this one measure, what was it? And, you know, it's they're making it progressively more hard. They are. You really have to. And I don't know if I'm answering this question too early, but you could kind of gotten away the first year with doing it really late. And even last year, you could kind of do it like this year. I would not advise it. And I think going into like next year, I really think you need to start thinking about literally January 1st, January 2nd, whatever you want to do. Get going on a strategy because it's probably not going to be that bad. But it's much, much easier to do it then. I even feel like I'm doing a little bit later than I wanted to. But, you know, I think with COVID going on and everything, I think a lot of people's lives are very different. I kind of went to the back burner. So, you know, that's what I would recommend, really get going early because you just don't know what's coming around the corner every year. It's going to be different, maybe not worse, but it's going to be different. Absolutely. So what advice would you give your fellow members? Or so besides that? Yeah, so I think definitely. So, yeah, get going early. What's your team, your MIPS team, if you want to call it for a guy like me, it doesn't have to be a big billing company or you can do self-billing, your office manager. And then whatever method you want to report. I don't know if a lot of people out there like me are doing software, but, you know, if you chop around for a software company, do you like their customer service? Is it easy to get in touch with them? Do they seem helpful? I don't really know if there's like reviews. I didn't really bother because I was fairly happy with what I've been using. And then if you have other people you can talk to that that so helps, like other practitioners in your same specialty that that does help a lot because doing it on your own, it's easy to kind of just start wandering off and you don't really realize that you weren't really. So. Yeah, no, that's great. And then how do you think a PM&R could help you out with MIPS reporting? What's what things would you like to see from a PM&R? Yeah, I thought about that. I mean, I think, you know, I think, you know, we have such a broad, diverse specialty. I would say a couple of things are maybe break down, you know, let's think about like, OK, what are the types of main populations? You know, we've got the outpatient guys, we've got the sports guys, we've got the interventional and then we've got guys like me, you know, and everyone's going to kind of report something different. I think within those sub communities. Oops, sorry. A PM&R, I think, you know, I found you or I found this thread through the forum, I think we have a fairly robust, very friendly forum and people are very helpful. I think maybe, you know, even this year is not too late, but going into next year, I think we should start a thread or within the various sub communities of PM&R and say, hey, you know, this is the MIPS inpatient guys or gals threat and let's start talking about, OK, what are we going to do? Because that's like leverage, because, you know, who knows? You know, I mean, my medical director may start doing his own thing and he may not do something right. And I think if we just leverage ourselves as a community, at least through the forums, boy, that's a lot better. I mean, you know, we can start to really screen out and say, hey, what's what's going to be easy? What's going to be hard? What can we do? And start doing this again really early, like January, February, March. Let's don't wait till like, please don't wait till like February. The following year, I mean, I hear stories like the company you says, like, you know, there's literally guys like, you know, one. Yeah. And that's here, right? The bad that that's got to be insanely stressful. Oh, yeah. Yeah. So I think we should leverage our community or use the forums or at least whatever to I think the forums are really nice. I've said that several times because it is very it's it's seems to be fairly active. There's always people put up posts every day or replies. Yeah. All right, well, that's great. That was very insightful and certainly it's it's great to hear from the solo practitioner and how they approach it and especially how your sort of strategy in terms of reporting on MIPS and I think great advice for the audience. And so thank you so much, Stephen, for joining us today. So thanks for having me. My pleasure. All right. Take care. All right. So that was Dr. Stephen Yang. And he practices out of the Houston metro area. So I know the beginning of the video was cut off. But yeah, he's a solo practitioner, predominantly doing inpatient consults. And now we're going to hear from a reporting experience from a small practice. So we're going to introduce our next speaker. This is Dr. Kwasnika. She's one of our panelists that's going to discuss and share her experiences in regards to MIPS reporting and how she does it in her practice. Dr. Kwasnika, hi, welcome. Hi, thanks for having me, Mark. So I'm going to share the slides for Dr. Kwasnika and she's going to just go ahead and start with the slides. So my experience is from the position of a small private practice. But we have some challenges because we are a neuro rehabilitation practice. We see inpatients and outpatients. And so I can kind of help you see what we have gone through with regards to MIPS and what we're still going through. So the practice is Valley Physical Medicine and Rehabilitation. We are a single specialty practice. We provide rehabilitation services at Barrow Neurological Institute. So we see patients in consultation in the inpatient rehabilitation realm, outpatient rehabilitation, which is run by Barrow Neurological Institute actually take place in the same building where our practice is. And then we see people chronically over time after their injury. It is a physician known private practice. We have at this time four PM&R doctors and three nurse practitioners. That number has changed over time. And we we've definitely grown from a low of two PM&R doctors and one nurse practitioner up. And as I said, we provide inpatient and outpatient treatment, which which does provide us some challenges with regards to MIPS, though much of what I'm going to talk about is actually what we do in the outpatient realm. So our platform for for our computer is eClinical Works. And we actually were in another platform and called EMDs. And we actually changed to eClinical Works because of their ability to monitor quality and allow us access to the MIPS information. So we could be more a part of how we change our practice and approach the patients. It also has a functional patient portal, which was a problem with the other platform as well. We use a CMS quality measures document as a cross reference. So the way this works, and I think that the challenge has been for me is MIPS is not just a thing. You have to choose what your measures are going to be. You have to then figure out how you're going to measure those measures and how you're going to make the computer system work for you so that you don't have to do extra steps. So originally when we did PQRS four years ago, at that point in time, there was a lot of manual pulling of data from the computer because the computer didn't keep track of things or maybe you documented falls, but you didn't actually have a documented fall measure. And so it wouldn't easily pull the data out. So now we actually have a system that can pull that data out for us. But we still have to be smart enough to figure out which CMS quality measures are going to be the ones we're going to use. And I think that's one of the biggest challenges. We have a designated MIPS consultant through our EMR. They, of course, spend most of their day working with primary care doctors. So we've had to teach them a lot about what we do and why some of the things they've said that we should do really don't make sense for us. But I think we've trained her throughout all of this. And I think that we're finally getting a handle on how we can adjust our measurements if we see that the workflow in our practice is not very good to get those measurements out of the medical record. So with that, quick question, though, Dr. Koznicki. So with that consultant, do they address all the issues like quality, improvement activities, cost, and promoting interoperability or meaningful use base? They do. The funny thing is that we actually, interoperability has been a, like, it's just, it's so hard to prove between multiple different medical records. Everybody's on a different platform. And it's interesting where I thought they would be so good at that because they're computer people. I recently had to explain to her how we all have two email addresses. We have a practice email address and an academic email address given to us by the institution. And they had signed us up in the practice email address to do our, to do the interoperability or be able to receive referrals from outside places. And the physicians are all in their academic email address because that's how we communicate with the hospital all day. So she was completely confused as to how that could happen. So I kind of, sometimes I have to step back and kind of explain to her, like, what, how we run our day so that she can understand that. So it's better than nothing. I have to tell you, before we had really nobody who helped us. We just figured it out on the fly. Having somebody who can go back and help us is, has been a huge, it's a huge thing. And a lot of the platforms actually, when we were changing, a lot of them had these people. You had to ask for it, though. So they, they like to do a quick, quick training when they give you, when you sign on. And then they kind of let it just go from there. So I would say, I would tell people to ask, basically. So, so our approach was, we came up with a list of quality measures we wanted to aim for. And you really need to choose more than you need to report, because you're just not going to meet some. And so then what we did was, we met with our consultant and we asked, basically, how does, how does the medical record measure the numerator and the denominator for each one of those quality measures? And once we kind of figured that out, we then had to sit down with the providers and the medical assistants to decide a workflow for each measure. So who's responsible for the last piece of information that's going to basically trigger the computer to count things? And so we are still working through that. And really, it is, the challenge I'll go on to has been that our workflow changed when telehealth came on board. And we didn't, at the moment, when we were all frantically dealing with COVID, we didn't think to go back and re-look at those measures because the way we collected information changed. So we really kind of had to sit down and say, OK, now, at this time, how are we going to go back and collect that information? So the medical assistants are vital in this, in workflow because if they don't record the information, if a patient comes in and just says, I don't want to weigh, and I'm just going to give you a number, and then they don't put in any information, you're never going to be able to catch the BMI information or whatever. So they are very important to all this. You can track it real time in our EMR. I can pull it up. I do pull it up from time to time so I can see where we're at. I also have to remind myself that there are certain measures that we, like, we've topped off on some measures. And there's a couple that, like, I don't know how we're ever going to meet them. But they're extra. So we, just to not panic or to look and make sure if you're finding something where the measure has a numerator of zero, now we're missing something. And you have to go back and figure out what we're missing. Next slide. So what are the challenges? And the challenges are huge. The measures don't always reflect what our practice is like. Our practice is patients with severe disability. We're not the primary care doctors. But they oftentimes view us as their point person, their primary care person. And so that is a huge challenge because how do you measure things but things that you might not be as responsible for tackling? Like, for example, bone density was one of the things we originally thought, oh, we should measure that. But really, the measures for bone density are for elderly women and really don't meet our population and what we're looking to accomplish with them. Telehealth changed how we initiated a visit. So what happens here when you come in is you get a depression screen, a fall screen. All that kind of stuff happens. And my brain injury patients can't even make it through the entire review systems, which is like a form as they come into the appointment. It's a click form. And half the time, halfway through the review systems, they're like, I'm done, or I didn't plan far enough in advance. I'm not here in time for the appointment. So we actually had to back it out, and what we did was we had the nurses or the MAs calling beforehand and doing those things for them on the phone. So the best laid plans, we had to get back into getting that kind of information. And then as you asked about the electronic referral loops, first of all, how do you know what's used? It seems like we do receive data electronically, which we then refer, we do see, and then we send a letter back. All of this is done electronically. There's no paper whatsoever. But that's not enough. You have to really show that you use some sort of electronic system to bring the referral in and that you're sending the referrals out. And different programs don't like to talk to different programs. And so there is a third party system that our EMR uses. We're having a very hard time with getting that to consistently bring in those referrals. So we found a group of practices who are on our platform, because sometimes it's just about looking like you check the boxes. And so the urology group, the large urology group, also uses our platform. So it's become very easy for us to send between ourselves. I know it's not the true spirit of NIPS, but boy, at least you know that you're going to be able to check yes to that and get that one done, because you don't have many options on that side. Other possible solutions. So we have designated a lead in the practice who's interested in NIPS. That's me. I've been very interested in how a electronic medical record can help us. I work in multiple different settings throughout the hospital. I go to a state clinic. So I'm in lots of different EMRs on any given day. So I can see the pros and cons. And that really helps me kind of be able to have that point person or be the point person. And then we hired a college student who has an interest in medicine to help with some of the computer workflow to teach our staff, because that's one of the hardest parts. The medical assistants need to understand how important their information is. And he's also working on integrating forms that can be directly uploaded into the record. So if you can directly upload a form, it counts better. So I would say that has really been one of the best things we've ever done. And he's getting experience in his quest to go to medical school. And we're getting his technologic knowledge. And he just has a little more time to talk to people at the EMR when we're trying to figure something out. And he can get that information and bring it back to us. So it's at least made it a little bit easier this go around. Now, that sounds great. So I think the advice is to know what your EMR can do for you. Know what its limitations are. Don't avoid your decisions until the end of the year. This year, if you look at the APM on our website, they're talking a lot about how do you file for a hardship waiver. And I don't disagree with that, because telehealth really, really kind of messed up what, at least at the small practice side, what we were doing. And there were a lot of other things that were distracting us. But don't wait till the end, because it's nearly impossible to get out of that hole. And then we need somebody to advocate for why our specialty is so different. It's really hard. My husband is a primary care physician. Boy, this stuff is so much easier for him. Like, so easy. And everybody wants to help them, and they have all these ways in which they get, you know, they get benefits of providing quality care. And we're providing the same thing. But because we're so different from each other, it's really, really hard to get anybody to understand what our specialty needs are. So we need to really advocate for that or figure out a way that we can fit our square peg in a round hole. Absolutely. Yeah. So as I thought about this, I don't want to, you know, I don't want to talk bad about the Academy. I just want to say that it would be really nice to have preloaded bundles for TBI and SCI. It would be really, really nice to advocate to CMS about why there needs to be some measures of these sort of things. There's stroke measures, yes, but not all of us do stroke. And then also advocating for when our patients don't fit in those measures. A lot of my patients are on antidepressants, SSRIs, for cognitive reasons. And they don't have a diagnosis of major depression. I'm not going to put the diagnosis of major depression on there. And it kills me every time. We cannot use that measure because of my patient population. So getting them to understand why those quality measures don't work for us, we see the same thing on the inpatient side when we look at it. You know, there's just some things that we do that aren't reflected in what anybody else does in regular hospital care. So I think this is where the Academy needs to step forward and help us tell that story to people. I think I agree with you, you know, that PM&R is such a unique specialty. There's really a severe lack of specific measures that really address what physiatrists do on a day-to-day basis. So and especially your point about, yes, there's some things on stroke, but that's because there's neurology. But there's not as much on brain injury, because that's not as sort of a hot topic for these quality measures. So I absolutely agree with you. I'm actually going to cover in a later portion of our presentation what the Academy's been doing to try and focus on that and how they can help, especially in those areas, especially trying to identify quality measures that might be relevant for your practice. But I think this is great. The advocacy piece is very important, really, the relevance of why you put patients on antidepressants and what agents you use and in the brain injury realm. And absolutely, these are measures that are missing. So I'll discuss that more later. But thank you, Dr. Kwasnika, so much for your presentation. I think that was great advice and really showing a small practice that's kind of working closely with the EHR to really try. And they're really trying to pay attention to their MIPS score and how they do best in it. So I think that's great. I'm going to stop the show. That was really a great wrap up from Dr. Kwasnika as far as a small practice. So just going to wrap up, because we're sort of running over in terms of time. But really, I think, of course, the challenges you've heard, there's not a lot of things that are specific to what we do in PM&R. So I think that's really the challenge we face. And so how can the AAPM&R help you? So really, one way, if you have questions as a practitioner, you can always email the Academy. And they can even work with you in terms of trying to look at your common CBT codes and even try and do a search to figure out to help assist you in terms of what measures you may want to look at from your practice standpoint. But what else is AAPM&R doing? So they have been really active in terms of urging CMS to try and remove and revise in collaboration with the AAPM&R the physical medicine specialty measures. So if you looked at that slide, again, from Bob Jasik, you're going to see there are some things that are somewhat relevant, but they really aren't reflective of what we do on a day-to-day basis. And your Academy continues to seek, through the annual comment periods, whenever they're trying to put up the final rule for each year, they're trying to put together comments and do advocacy for our specialty with CMS and legislation. And then finally, we do have the data registry, which Bob's referred to. We're getting sort of rebooting that to really look at some additional pilot sites and really, hopefully, in the long term, create measures that are more specific for AAPM&R. And then really, a couple of things that are upcoming. So in March, we're going to be holding the, there's going to be an annual MIPS webinar, which more information will be coming. They'll be updating their web pages, because they've heard feedback they need to get these to look better and be easier to navigate. And they're releasing annual updates in regards to the reporting guides for each of the four components of MIPS. And then, again, on an annual basis, they're really trying to work with, they attend national quality conferences to promote AAPM&R. They're meeting with stakeholders from various national organizations, including CMS. And then they are always looking for people to apply for national technical expert panels. So if you see that little link there at the bottom for volunteer opportunities, or the Academy is always looking for people to volunteer for that and just, you know, volunteer. I mean, it's great to be part of it. I was actually fortunate enough to be part of two different panels. One was CMS for actually their measured development planned technical expert panel, in which PM&R was identified as a critical need specialty to get additional measures developed. Unfortunately, we don't have those yet. But at least it was identified as a need. So it is a start. And then I also participated in the national quality forum measure feedback loop. So it's really trying to look at existing measures and how do we improve on the measures that we have now. And then even for future measures, how do you provide feedback for that? So getting our involvement, getting physiatrists involved, each of these areas is going to be really important to help forward our specialty. And I think we need to unite. We need to, as a specialty, we need to actively create ways to show the value that physiatry adds to health care. And so that finishes our presentation on MIPS. Obviously, it's still the score peg in the round hole phenomenon, unfortunately. But hopefully over time, we'll be able to change that and make MIPS reporting much more relevant for what we do as a specialty.

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