MVP: Optimal Care for Kidney Health
Most applicable medical specialty: Nephrology
The Optimal Care for Kidney Health MVP focuses on the clinical theme of providing fundamental treatment
and management of costly clinical conditions that contribute to, or may result from, kidney disease.
Quality
To fulfill quality requirements:
- You must select 4 quality measures from the list below
- (exception for clinicians in a small practice – see # 4 below)
- At least 1 measure must be an outcome measure
- If no outcome measures are available, you may report a high priority measure.
- If you are part of a small practice (i.e., 15 or fewer clinicians) reporting quality measures through Medicare Part B claims, you don’t need to report additional measures beyond the Medicare Part B claims measures available in this MVP. Reporting all of the Medicare Part B claims measures in this MVP will fulfill your quality reporting requirements.
- You must collect data for each measure for the 12-month performance period of the associated performance year (e.g., January 1, 2025 – December 31, 2025).
TIP: For small practices (participating at the individual, group or subgroup level) reporting Medicare Part B claims measures: To meet data completeness requirements, you’ll need to start reporting the Medicare Part B claims measures in your selected MVP in January 2025, prior to the MVP registration period.
TIP: Make sure that you select measures that are appropriate to your patient population. Measures that don’t meet case minimum or data completeness criteria will earn zero points.
| ID | Title | Specs |
| 001 | Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | Details |
| 047 | Advance Care Plan | Details |
| 130 | Documentation of Current Medications in the Medical Record | Details |
| 236 | Controlling High Blood Pressure | Details |
| 482 | Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate | Details |
| 487 | Screening for Social Drivers of Health | Details |
| 488 | Kidney Health Evaluation | Details |
| 489 | Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy | Details |
| 493 | Adult Immunization Status | Details |
| 495 | Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood | Details |
| 503 | Gains in Patient Activation Measure (PAM) Scores at 12 Months | Details |
| 510 | First Year Standardized Waitlist Ratio (FYSWR) | Details |
| 511 | Percentage of Prevalent Patients Waitlisted (PPPW) and Percentage of Prevalent Patients Waitlisted in Active Status (aPPPW) | Details |
Improvement Activities
To fulfill improvement activity requirements:
1. You must report 1 improvement activity from the list below.
Beginning in 2025, improvement activities don’t have assigned weights.
| ID | Title |
| IA_AHE_3 | Promote Use of Patient-Reported Outcome Tools |
| IA_AHE_9 | Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols |
| IA_BE_4 | Engagement of patients through implementation of improvements in patient portal |
| IA_BE_6 | Regularly Assess Patient Experience of Care and Follow Up on Findings |
| IA_BE_14 | Engage Patients and Families to Guide Improvement in the System of Care |
| IA_BE_15 | Engagement of Patients, Family, and Caregivers in Developing a Plan of Care |
| IA_BE_16 | Promote Self-management in Usual Care |
| IA_CC_2 | Implementation of improvements that contribute to more timely communication of test results |
| IA_PM_26 | Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B |
| IA_CC_13 | Practice Improvements to Align with OpenNotes Principles |
| IA_MVP | Practice-Wide Quality Improvement in MIPS Value Pathways |
| IA_PCMH | Electronic submission of Patient Centered Medical Home accreditation |
| IA_PM_11 | Regular review practices in place on targeted patient population needs |
| IA_PM_13 | Chronic Care and Preventative Care Management for Empaneled Patients |
| IA_PM_16 | Implementation of medication management practice improvements |
| IA_PSPA_16 | Use decision support—ideally platform-agnostic, interoperable clinical decision support (CDS) tools —and standardized treatment protocols to manage workflow on the care team to meet patient needs. |
Cost
Important information to consider:
- You don’t have to submit any data for this performance category. We’ll use Medicare claims data to
calculate your cost measure performance.
(You don’t select cost measures during MVP registration. CMS will calculate your performance
on all the cost measures included in the MVP based on available Medicare claims data.) - You’ll only be scored on the cost measures in this MVP for which you meet or exceed the established
case minimum.
| ID | Title | Specs |
| COST_AKID_1 | Acute Kidney Injury Requiring New Inpatient Dialysis | Details |
| COST_CKD_1 | Chronic Kidney Disease (CKD) episode-based cost measure | Details |
| COST_ESRD_1 | End-Stage Renal Disease (ESRD) episode-based cost measure | Details |
| COST_KTM_1 | Kidney Transplant Management episode-based cost measure | Details |
| TPCC_1 | Total Per Capita Cost (TPCC) | Details |