Thank you for making the Azara 2022 Annual User Conference a great success!

Skip to content

Improving MIPS Scores with Better Data and Better Practices

How one company boosted its quality, care, codes and scores in just months

You’re a respected, well-thought-of, big-time contributor to the healthcare of both your community and region. Your group practice is packed with esteemed physicians and caregivers that have across the board received thumbs-ups from patients and the industry. So why is your group ranked by CMS as just barely average in quality of care and cost? Turns out the devil is in the details. Or more specifically, the data.

The first sign

University of South Florida (USF) Health is an academic physicians group practice based in Tampa with 1500 resident physicians, 700 clinical providers, and 190,000 active patients. Early in the first year of participation in MIPS under the Quality Payment Program (QPP), CMS provided USF with a Quality and Resource Use Report (QRUR) – a chart depicting how your organization fares in the quality and cost of care you provide in comparison to other healthcare institutions.

What the chart showed was a bit deflating:

MIPS chart showing starting point


The discovery

After a short period of self-reflection, USF determined they were in fact not being derelict in their healthcare tasks, but rather inconsistent in their documentation of those tasks. This communication breakdown had also metastasized into quality data codes that were not being entered comprehensively into USF’s EHR, roadblocking many good performance reports from being represented. Things weren’t looking rosy for USF’s inaugural foray into MIPS at this stage, which prompted USF Chief Quality Officer Terri Ashmeade, MD, to spring into action.

The remedy to low MIPS scores

Dr. Ashmeade, a neonatologist by trade and self-described “quality improvement nerd,” initially boned up on published online narrative about “transforming clinical practices initiative” and “quality impact.” Realizing that USF’s dilemma largely revolved around data and personal/departmental engagement, Ashmeade decided to call upon USF’s longtime IT partner SPH Analytics.

First item on the agenda: the data. “The data we needed was not coming through to us in the form we needed to act upon,” says Ashmeade. “Getting the raw data now better aggregated and produced through SPH’s Population Care solution at last made me see.”

“Once we were getting the data in the format, quality, and codes we needed, I started to see where our gaps in care were, and the areas that we needed to show some improvement on.”

The improvement

Here comes the hard part – doing the actual improvement. Fortunately, Ashmeade had the manpower to pull off these feats. Maybe even too much manpower! “I have 500 physicians, 200 nurse practitioners and PAs, plus thousands of members of their care teams who need to do the heavy lifting here.”

“How am I going to have conversations with all the providers, and then administrators, and then the care teams to help improve patient care and outcomes?” Ashmeade wondered. “And then I had to think what was going to drive them.”

She started at the top. “I got the head doctor, head administrator, and head nurse together in meetings and showed them the initial round of the aggregated data that came from SPH, which got them engaged enough to act. And that in turn got filtered down through the ranks.”

“So not only did the new data show where quality could use some improvement,” Ashmeade continued, “more than a few signs of excellent and even perfect performance were noted which in their own way proved as inspirational as the more sobering findings.”

But it’s the areas in need of improvement that required the focus to gain those precious MIPS numbers. To boost things up on the physician side, Ashmeade briefly (and reluctantly) played the ‘fear card.’ She explained about the always unpleasant MIPS “negative adjustment” factor and how it grows when the improvements don’t happen. Ashmeade also brought up CMS publishing its Physician Compare listing which will offer side-by-side comparisons – and performance scores! – with other physicians who share disciplines. “Our physicians are super competitive, so seeing how they were performing alongside other physicians was very incentivizing.”

Enhancing the standardized practices

The real meat of the continuous improvement effort, however, lies in the standardized practices. But the key is not to add more processes to the list, but to make the ones you’ve got more focused, more valuable, and beneficial to the cause.

“You have to assume that everybody is already working their hardest,” Ashmeade continues. “So we started to put standardized practices in place for the medical assistants and tools in place to help remind the care team in their already existing workflows to question the patient about key health issues.

“For example, take an event as simple as asking a patient if he smokes. And if the answer is yes, suggesting that he stops because it’s bad for him. By executing and documenting that simple act for all patients, whether it’s done by a medical assistant or a doctor, that’s a checkmark for a good MIPS rating.”

USF’s tobacco cessation program improved to be a valuable contribution to an improved CMS rating, but it wasn’t the only one. “We did a similar effort for our diabetic patients,” says Ashmeade. “Reduced the number of patients who had their hemoglobin/A1C out of range, which in turn meant fewer patients who would go blind, who would lose their feet or even legs, fewer heart attacks – all of those complications that happen if your diabetes isn’t under control.”

And blood pressure management is yet another success story. “We have 2500 more people with controlled blood pressure this year than the year before,” Ashmeade added. “Prior to SPH’s Population Care, we always thought we were properly managing blood pressure. But if you don’t have the data in front of you to show you where you’re not connecting with a blood pressure sensitive population, you’re not going to improve.

“This is so much more consequential to positive outcomes when we’re able to use the data to improve.”

“Improves the meaningfulness of the work our care teams are doing”

“By using the data and graphs generated by SPH’s Population Care, our MAs and doctors were collectively able to identify those issues needed to screen the right people. It improved the care for the patient, and the patients were happier.” Dr. Ashmeade concluded that the solution is “a super powerful tool that we have been able to use that not just impacts people’s lives but improves the meaningfulness of the work our care teams are doing every day, both on an individual basis with our patients and as a population.”