In this episode of Ask Dr. Mingle, Dr. Dan Mingle explains the difference between MIPS Value Pathways, EMA Clusters, and Specialty Measure Sets. Later, Dr. Mingle clarifies the new Query of PDMP requirements for the Promoting Interoperability Category and shares insight into exclusions for the measure.

Click play to listen to this episode now:

Question One: MIPS Value Pathways (MVPs) vs. EMA Clusters

Carrin asks: “Can you help me understand EMA clusters and MIPS Value Pathways (MVPs)? How are they similar? How are they different?”

Great question, Carrin.

There’s a third topic I’ll toss into the mix. Any discussion comparing EMA clusters to MVPs must also consider Specialty Measure Sets.

First, each of these three topics works in different ways to achieve two functions critical to quality submissions:

• They help to guide measure selection.
  • Providers often need help to find measures applicable to their specialties.
• They help determine when to permit a submission of fewer than six measures without penalizing a provider or group’s scoring potential.
  • It’s neither desirable nor fair to penalize a provider or a group practice when they cannot find six measures that apply to them to analyze and submit.

Each method differs in approach concerning the two functions above.

“EMA” stands for “Eligible Measure Applicability”

EMA is primarily a retrospective analysis of a short set of measures. EMA topics tend to be around a clinical topic rather than a specialty. The cluster can be representative of a subspecialty, or it may cross specialty lines.

• In EMA for 2022, 42 measures sort into 12 clinical topics. Each group of measures mapping to its topic is considered an EMA cluster.
• Medicare applies EMA analysis after submission to analyze submissions containing fewer than the required six measures. When any submitted measure maps to one of the EMA clusters, Medicare assumes the provider could have and should have submitted all the other measures in the cluster.
• After accounting for EMA clusters, to the extent Medicare does not identify other measures a provider should have submitted, scoring is adjusted to eliminate any penalty for too few submitted measures.

Specialty Measure Sets

“Specialty Measure sets” include the measures CMS thinks apply to a specialty.

EMA clusters can look like Specialty Measure Sets but tend to be a single clinical topic that can be within a specialty or bridge multiple specialties.

Specialty Measure Sets are intended to be used proactively as a guide for a specialty provider or group to choose appropriate measures. But they are also treated as EMA clusters when Medicare retroactively analyzes submissions with fewer than six measures.

For 2022 there are 47 Specialty Measure Sets into which sort 196 measures.

• The number of measures that sort to each specialty ranges between 2 and 62
• 42 specialty measure sets contain 6 or more measures
• 5 specialty measure sets contain fewer than 6 measures:
  • Dentistry at 2 measures
  • Cardiac Electrophysiology at 2 measures
  • Hospitalists at 5 measures
  • Radiation Oncology at 3 measures
  • Speech and Language Pathology at 5 measures
• CMS scores the submission as complete with a reduced denominator if a provider or group submits all of the measures in a specialty measure set with fewer than six measures.

MIPS Value Pathways (MVPs) are the newest addition to this theme.

MIPS Value Pathways (MVPs) have been under development for several years and just became available for use for the first time in the 2023 Performance Year.

MVPs can have a specialty focus, like specialty measure sets. Or they can have a clinical topic focus like EMA clusters.

Each MVP defines a complete submission measure set, like Specialty Measure Sets and EMA clusters. Once you have chosen an MVP to submit, you don’t need to add other measures for a complete submission.

Unlike Specialty Measure Sets and EMA clusters, each MVP includes Cost measures and practice Improvement Activities related to the same specialty or clinical topic.

• Medicare has proposed a development and ramp-up schedule that will steadily increase the menu of available MIPS Value Pathways and, potentially, as early as the 2028 Performance Year, end the current MIPS program they are calling Traditional MIPS and transition entirely to MVPs.
  • After the transition, we should expect EMA clusters and Specialty Measure Sets to no longer be needed or supported.

Question Two: Query of PDMP

Carole asks: “For Promoting Interoperability, the Physician Drug Monitoring Program query is now a requirement. However, our providers don’t prescribe any controlled substances. We have, thus far, not enrolled in EPCS as we didn’t need it and it was expensive through our EHR product. Our EHR vendor has told me that in order to be enrolled in the PDMP query, we must also enroll in EPCS. This seems all very silly since our infectious diseases and Lipid Clinic physicians don’t ever prescribe controlled substances. I have been unable to find an exclusion for this measure. Is there an exclusion I’ve missed? Or do we have to spend all this money for something we don’t use just to stay compliant for PI?”

This is an excellent question with six components to the answer:

• What is a PDMP query?
• What is EPCS?
• What does it take to pass the PDMP measure in the Promoting Interoperability performance category?
• What controlled substances are covered by the PDMP measure?
• Is there an applicable exclusion for this measure?
• And finally, how do I apply this to your specific situation?

What is a PDMP query?

PDMP stands for Prescription Drug Monitoring Program. It’s usually a Statewide solution, and there is progress toward a national roll-up of those programs.

Programs tend to require pharmacy participation and recruit prescribing providers to use the service. At last tally, 49 States, DC, and Guam have operational programs. Missouri is the final State to be working toward implementation and may be up by now.

When prescribing a controlled substance, the prescriber will check the PDMP for a record of controlled substance prescriptions previously provided to the patient.

The intention, of course, is to identify when a patient is acquiring controlled substances from multiple sources as a sign of abuse.

Procedures for accessing the program can vary from State to State and can include the following:

• Phone-in queries
• Direct web-based login and query
• Integrations directly between the PDMP and EHR
• Integrations between the EHR and a national PDMP clearinghouse
• And specific programs might accept logins from the prescribing provider or the provider’s staff

What is EPCS?

EPCS stands for Electronic Prescribing of Controlled Substances and is governed by the DEA and individual state boards of pharmacy.

The requirements are:

• Appropriate DEA credentials
• Proof of identity by some authority (can vary from region to region)
• And 2-factor authentication to electronically sign prescriptions

What are the requirements of the Query of PDMP measure?

The measure is an attestation:

• “Has the required action been performed at least once by the individual provider or at least one provider in the group, Y/N?”
• The required action is to query the local PDMP to access the patient’s history when prescribing a controlled substance.
• The rule states: “MIPS eligible clinicians have the flexibility to query the PDMP using data from CEHRT in any manner allowed under their State law.”
• This applies to electronic or manually written prescriptions.

It only has to be integrated with the EHR if that is the only way your local program permits query, and it does not require credentials for EPCS.

What controlled substances are covered by the PDMP measure?

Before 2023, it only applied to Schedule II drugs. Starting in 2023, it adds Schedules III and IV drugs.

• Don’t view this as more restrictive. It’s more lenient. Since it only requires one query in the year to pass, you can now pass by querying for a Schedule III or IV drug if you don’t prescribe Schedule II drugs.

Can I use an exclusion in my practice where I do not prescribe controlled substances?

Three exclusions apply to the PDMP measure:

1. If you’re unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period.
2. If you write fewer than 100 permissible prescriptions during the performance period.
3. And if querying a PDMP would impose an excessive workflow or cost burden before the performance period you select in 2023.

How can you apply all of this to your specific situation?

Based on your question, we know the following:

• You have a specialty practice dealing with infectious disease and as a lipid clinic.
• You have an EHR.
• You electronically prescribe, but you don’t prescribe Schedule II drugs.

So, what can you do?

• You don’t need to implement EPCS. You don’t prescribe them. It’s a waste of time and money.
• Even if you prescribe controlled substances, you don’t need to be electronically interoperable with your PDMP:
  • The key phrase in the rules is “… (you can) query the PDMP … in any manner allowed under … State law.”
  • If your local PDMP permits you to log in online and manually search the database, that qualifies.
  • You must interface if that is the only way your PDMP permits query.
• You only need to do it once to pass the measure. And only one of you needs to do it once:
  • You can’t just check the PDMP on your prescription for a non-scheduled drug. The specifications are specific to scheduled drugs.
  • But think about more than Schedule II drugs. Starting in 2023, you can also query about your Schedule III and IV drugs.
    • If any provider in your group prescribes a Schedule III or IV drug and logs in to your local PDMP to check the drug history of that patient, you can attest “Yes” to this measure.
• If you still can’t pass this measure on a Schedule III or IV drug, you can use an exclusion:
  • You probably can’t use the “fewer than 100 prescriptions” exclusion. It applies to all scripts, not just controlled substances. The 100 scripts is not an annual number; it is counted only for the selected performance period, which can be as short as 90 days.
• What exclusions may apply to your situation?
  • I like the “Unable to electronically prescribe…” exclusion for you.
    • If you consider: “my scope of practice doesn’t allow me to prescribe controlled substances.”
  • The “…excessive workflow or cost burden…” exclusion is equally applicable.
    • Certainly, spending anything on functionality you don’t need and won’t use is excessive.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, Primary Care First, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.

On LinkedIn, leave your questions in a comment on any of our posts.

And you can reach out directly by sending an email to hello@minglehealth.com.