Part II: MIPS Quality Performance Category in 2020
Editor’s note: This article is the first part of a five-part series on the Centers for Medicare and Medicaid (CMS) Quality Payment Program (QPP) in 2020.
- Part I provides an update to the current requirements for MIPS, emphasizing key components that changed in 2020.
- Part II will discuss the current requirements for the MIPS Quality performance categories.
- Part III will focus on the current requirements for the MIPS Promoting Interoperability performance categories.
- Part IV will detail the requirements for the cost and improvement activity performance categories of MIPS and MIPS audit considerations.
- Part V will review the 2020 QPP Alternative Payment Models and MIPS APMs.
By Michael Stearns, MD, CPC, CFPC, CRC
Quality Category Weighting in 2020
The Centers for Medicare and Medicaid Services (CMS) elected to maintain the quality category weighting at 45 percent in 2020. This figure will impact most MIPS participants. However, certain clinicians and groups may be eligible for reweighting of the Promoting Interoperability (PI) category of MIPS to zero percent (e.g., clinical psychologists and certain other clinician types, hospital-based clinicians, non-patient-facing clinicians, those that claim a PI hardship exception, etc.). For these practices the PI category’s 25 percentage points will be reallocated to the quality category, giving it a weighting of 70 percent. Other practices may not have their cost performance category reweighted to zero points. When this occurs the 15 MIPS percentage points in this category are in most cases reallocated to the quality category. In some settings the final MIPS score may be determined based on weightings of 85 percent quality and 15 percent improvement activities.
CMS organizes quality measures into groups referred to as “collection types” that have comparable specifications and data completeness requirements. The quality measure collection types are:
- Electronic Clinical Quality Measures (eCQMs)
- Clinical Quality Measures (CQMs)
- Medicare Part B claims measures
- Qualified Clinical Data Registry (QCDR) measures
- CMS Web Interface measures
- The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey measure
- Administrative claims measures
eCQMs are used to report data on clinical actions electronically without the need for manual review. Practices must use 2015 Edition Certified EHR Technology (CEHRT) to generate eCQM data for reporting. CMS approved 46 eCQMs through the rulemaking process for 2020 (see Table 1 below). Eighty-nine percent of eCQMs have benchmarks for 2020. This is a relatively high number and significant as scores for non-benchmarked quality measures are capped at three points out of a possible 10. eCQMs are the future direction of quality reporting. However, not all electronic health record (EHR) vendors support the data collection and reporting requirements for all MIPS eCQMs.
|Table 1. 2020 MIPS eCQMs and Benchmark Status|
|Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)||1||Y|
|Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)||5||Y|
|Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)||7||Y|
|Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)||8||Y|
|Anti-Depressant Medication Management||9||Y|
|Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation||12||Y|
|Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care||19||Y|
|Appropriate Treatment for Children with Upper Respiratory Infection (URI)||65||Y|
|Appropriate Testing for Children with Pharyngitis||66||Y|
|Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients||102||N|
|Adult Major Depressive Disorder (MDD): Suicide Risk Assessment||107||Y|
|Preventive Care and Screening: Influenza Immunization||110||Y|
|Pneumococcal Vaccination Status for Older Adults||111||Y|
|Breast Cancer Screening||112||Y|
|Colorectal Cancer Screening||113||Y|
|Diabetes: Eye Exam||117||Y|
|Diabetes: Medical Attention for Nephropathy||119||Y|
|Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan||128||Y|
|Documentation of Current Medications in the Medical Record||130||Y|
|Preventive Care and Screening: Screening for Depression and Follow-Up Plan||134||Y|
|Oncology: Medical and Radiation – Pain Intensity Quantified||143||Y|
|Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery||191||Y|
|Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention||226||Y|
|Controlling High Blood Pressure||236||Y|
|Use of High-Risk Medications in the Elderly||238||Y|
|Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents||239||Y|
|Childhood Immunization Status||240||Y|
|Dementia: Cognitive Assessment||281||Y|
|Initiation and Engagement of Alcohol and Other Drug Dependence Treatment||305||Y|
|Cervical Cancer Screening||309||Y|
|Chlamydia Screening for Women||310||Y|
|Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented||317||Y|
|Falls: Screening for Future Fall Risk||318||Y|
|Follow-Up Care for Children Prescribed ADHD Medication (ADD)||366||Y|
|Depression Remission at Twelve Months||370||Y|
|Closing the Referral Loop: Receipt of Specialist Report||374||Y|
|Functional Status Assessment for Total Knee Replacement||375||Y|
|Functional Status Assessment for Total Hip Replacement||376||Y|
|Functional Status Assessments for Congestive Heart Failure||377||Y|
|Children Who Have Dental Decay or Cavities||378||Y|
|Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists||379||Y|
|Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment||382||Y|
|Statin Therapy for the Prevention and Treatment of Cardiovascular Disease||438||Y|
|Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy||462||N|
|Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture||472||N|
|International Prostate Symptom Score (IPSS) or American Urological Association-Symptom Index (AUA-SI) Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia||476||N|
The most frequently used collection type is MIPS CQM, formerly referred to as “registry measures.” CMS approved 196 MIPS CQM measures for the 2020 reporting year, a 16 percent reduction from 2019. Seventy-five percent of CQM measures have benchmarks for 2020. A list of measures, collection types, and requirements are available on the CMS Quality Payment website.
Data on CMS CQM measures can be abstracted via manual data record review or supplemented by EHR or third-party software applications. Data is then processed by a clinical registry or a Quality Clinical Data Registry (QCDR) and submitted to CMS via the registry’s application programming interface (API).
The Medicare Part B claims measure collection type is an option for small practices of 15 or fewer MIPS-eligible clinicians. CMS approved 55 Medicare Part B claims measures; 78 percent of these measures have benchmarks for 2020. Data is submitted by adding quality data codes to Part B Medicare claims at the time the claim is submitted for payment.
MIPS-eligible clinicians reporting through a QCDR may report on approved QCDR measures. CMS approved the use of 713 QCDR measures for the 2020 performance year. However, only 7.3 percent of these measures have benchmarks, which may significantly limit their use.
Groups of 25 or more clinicians may submit data on the CMS Web Interface measures. There are total of 10 CMS Web Interface measures and they are heavily weighted toward primary care.
Practices have the option of reporting performance data on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) quality measure, but must use a CMS-approved CAHPS vendor.
Administrative claims data is used to determine performance on the “All-Cause Hospital Readmission” Quality measure. This measure may be attributed to large groups of MIPS-eligible clinical types (16 or more clinicians) if the case minimum of 200 patients is met. CMS has developed a detailed attribution model that determines which clinicians and groups are attributed to this measure.
Practices have the option of submitting performance data on quality measures from multiple collection types (e.g., eight CMS CQMs and four eCQMs). CMS will use the six highest performing measures to determine the MIPS Quality score.
Quality Measure Types
CMS recognizes seven Quality measure types:
- Intermediate Outcome
- Patient-Reported Outcome
- Patient Engagement/Experience
MIPS Quality Reporting Requirements, Scoring, and Benchmarks
Practices are required to submit at least six quality measures to earn the highest possible score. The six quality measures must include at least one outcome measure or one high-priority measure in the absence of an applicable outcome measure. Outcome measures include outcome, intermediate outcome, and patient-reported outcome.
Subspecialties that do not have six applicable quality measures available should report on as many quality measures that represent the care they provide. As noted previously, large groups may be attributed a score based on the All-Cause Hospital Readmission measure. When this occurs CMS will determine the MIPS Quality score based on performance on seven quality measures.
To achieve the highest possible score, quality measures need to meet the data completeness requirements. CMS increased the data completeness threshold from 60 percent in the 2019 performance year to 70 percent in the 2020 performance year.
At least 70 percent of the MIPS-eligible clinician’s or group’s encounters/patients that meet the measure’s denominator criteria, regardless of payer, must be reported. The exception is measures that are reported through the Part B Medicare claims collection type, where 70 percent of encounters with Medicare Part B beneficiaries must be reported. Large practices that do not meet the data completeness requirement will receive zero points for the measure, a change from 2019 when CMS awarded one point per measure. Small practices continue to receive three points per measure when data completeness is not met.
Quality measures also have a case minimum of 20 patients. This has not changed from 2019. Measures reported that do not achieve the case minimum requirement will receive three points per measure, regardless of practice size.
Practices may submit data on an unlimited number of quality measures if the measures are applicable to their practice setting. CMS will base the MIPS Quality category score on the six highest performing quality measures submitted by the practice, or the top six performing measures and the All-Cause Hospital Readmission score if it is attributed to large practices. An exception to this is when the practice submits data on an outcome measure that does not have a benchmark or otherwise has a score lower than six or more other measures. CMS will include the outcome measure in the score determination. For this reason, it is advisable to identify and report outcome measures that have benchmarks established for the current performance year.
Scores per measure range from zero to 10 points, not including bonus points. The final score for the measure is scored against a benchmark for the measure, if one is available. As noted previously, for measures without benchmarks, the practice will receive a maximum score of three points unless CMS receives enough data to calculate a benchmark for the measure during the same performance year. For this reason, many practices will submit data on a least six measures that have established benchmarks.
Benchmarks vary by collection type for the same measure. Submitting the same measure through different collection types can improve the final score. Practices can submit measures via the eQCM, CQM, and claims collection types simultaneously.
Some measures with historically high performance have scores capped at seven points. The MIPS benchmarks for the 2020 performance year were released on December 31, 2019, and the benchmark file is available in the Quality Payment Program Resource Library.
Two measures had their benchmarks flattened for 2020 as CMS has concerns that performance on these measures could incentivize treatment that may not be appropriate for patient care. This is limited to the CMS CQM and QCDR collection types. The two measures are:
- MIPS ID: #1 “Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9 percent)”
- MIPS ID: #236 “Controlling High Blood Pressure”
The following example demonstrates how the final score for a Quality measure is influenced by its benchmark values.
MIPS CQM #110 “Preventive Care and Screening: Influenza Immunization” has the following 2020 benchmark values organized into deciles (see Figure 1 below).
|Figure 1: 2020 Benchmark Values for MIPS CQM #111|
|Decile 3||Decile 4||Decile 5||Decile 6||Decile 7||Decile 8||Decile 9||Decile 10|
|0.21 – 11.43||11.44 – 32.82||32.83 – 61.63||61.64 – 88.07||88.08 – 99.43||99.44 – 99.99||—||100|
Based on the benchmarks in Figure 1, if the practice reported that they met this measure’s performance requirement for 999/1000 patients, they would receive a score of 8.9 points. If they reported a performance met score of 880/1000 patients, they would receive a score of 6.9 points.
Quality Measure Bonus Points: Practices receive bonus points for certain quality measures:
- Each additional outcome measure: Two points per measure
- Each additional high priority measure: One point per measure
- End-to-end electronic reporting: One point per measure
The end-to-end reporting bonus is only awarded to CQM measures that do not have an equivalent eCQM and where the data, once exported from the EHR, is not manipulated prior to being submitted directly to CMS.
Points from the additional outcome and high-priority measures are summated and cannot exceed 10 percent of the denominator value, which varies based on whether the All-Cause Hospital Readmission measure is attributed to the practice (i.e., 60 or 70 points). The same limit is placed on the end-to-end electronic reporting measure. The data completeness and case minimum requirements must be met for practices to receive these bonus points. However, the bonus points will be assigned to the total MIPS score even if the outcome, high-priority, or eCQM measures have scores that are not in the six highest-scoring group of measures.
Small practices also continue to receive an automatic six-point bonus in the Quality category of MIPS.
Once benchmarks and bonus points have been applied to submitted measures, CMS will determine the score based on the six highest-performing measures.
In the example shown in Figure 2, above, the measures highlighted in green are the six highest-performing measures. The scores for these measures will be summated and, in this example, total 55.13 points. A small practice would also receive a six-point bonus, increasing their score to 61.13, which CMS would cap at 60 points. This represents 100 percent performance in this category.
Bonus points for quality measures may result in significant improvements in the Quality score. The example in Table 2, below, illustrates optimal use of bonus points.
|Table 2: Quality Performance Category Maximum Bonus Points for a 100-Clinician Practice|
|Six Highest Performing Measures||Measure Type||Score (based on benchmark)||Additional Outcome /High Priority Bonus Points||End-To-End Electronic Reporting Bonus Points||Summated Bonus Points|
|H||All Cause 30 Day Readmission Measure||6.0||None||0|
|*Measure not used in final score determination, but associated bonus points counted.|
Based on the example in Table 2, the patient would have a pre-bonus Quality performance score of 50.9 out of a possible 70 points, a 72 percent performance rate. With the bonus points this figure increases to 64.9 points, a 92 percent performance rate.
Data Aggregation Challenges: Practices that work in multiple settings of care, including when disparate EHR systems are used, are required to aggregate and report 70 percent or more of eligible encounters. Validating that 70 percent of encounter data is being reported requires the practice to identify 100 percent of encounters across these settings of care. Strategies to obtain data on quality measures from multiple databases may need to be negotiated with these practice settings.
Once the data is published, it must be aggregated by a CMS-certified data aggregator. Certified registries that are eligible to report MIPS data are in general also certified to aggregate data.
Hospital Value-Based Purchasing Program Option: Facility-based clinicians and groups have the option to use their Hospital Value-Based Purchasing (VBP) Program score instead of reporting additional quality measures. The requirements for a clinician to be facility-based include meeting all three of the following criteria:
- Seventy-five percent of covered services were provided in a hospital setting defined by Place of Service code, including:
- Code 21: Inpatient hospital
- Code 22: On-campus outpatient hospital
- Code 23: Emergency Department
- At least one service was provided in the inpatient or emergency room setting
- The EC or group can be attributed to a hospital that has a HVBP score. If a practice provides services at more than one hospital, CMS will attribute to the hospital with the higher score.
2020 Changes to the Number of Available Quality Measures
Three new quality measures were added for 2020 from the CMS measure pool (excluding QCDR measures) (see Table 3). Forty-two measures were removed (see Table 4). As a general policy, CMS will remove measures that do not receive benchmarks for two or more years, have historically high scores, are duplicative, or that are no longer felt to provide value clinically. CMS is also refining the process of measure approval with an emphasis on outcome measures that are harmonized with other aspects of MIPS, consistent with the MIPS Value Pathways (MVP) initiative proposed for 2021.
|Table 3: New MIPS Quality Measures for 2020|
|Measure CMS ID#||Measure Title||Collection Type|
|467||International Prostate Symptom Score (IPSS) or American Urological Association-Symptom Index (AUA-SI) Change 6 -12 Months After Diagnosis of Benign Prostatic Hyperplasia (eCQM only)||eCQM|
|477||Multimodal Pain Management||MIPS CQM|
|478||Functional Status Change for Patients with Neck Impairments||MIPS CQM|
|Table 4: MIPS Quality Measures Removed in 2020|
|MIPS ID#||Measure Description|
|#046||Medication Reconciliation Post-Discharge|
|#051||Chronic Obstructive Pulmonary Disease (COPD)- Spirometry Evaluation|
|#068||Hematology- Myelodysplastic Syndrome (MDS)- Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy|
|#091||Acute Otitis Externa (AOE)- Topical Therapy|
|#109||Osteoarthritis (OA)- Function and Pain Assessment|
|#131||Pain Assessment and Follow-Up|
|#160||HIV/AIDS- Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis|
|#165||Coronary Artery Bypass Graft (CABG)- Deep Sternal Wound Infection Rate|
|#166||Coronary Artery Bypass Graft (CABG)- Stroke|
|#179||Rheumatoid Arthritis (RA)- Assessment and Classification of Disease Prognosis|
|#192||Cataracts- Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures|
|#223||Functional Deficit- Change in Risk-Adjusted Functional Status for Patients with Neck, Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments|
|#255||Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure|
|#262||Image Confirmation of Successful Excision of Image-Localized Breast Lesion|
|#271||Inflammatory Bowel Disease (IBD)- Preventive Care- Corticosteroid Related Iatrogenic Injury|
|#325||Adult Major Depressive Disorder (MDD)- Coordination of Care of Patients with Specific Comorbid Conditions|
|#328||Pediatric Kidney Disease- ESRD Patients Receiving Dialysis- Hemoglobin Level < 10g/dL|
|#329||Adult Kidney Disease- Catheter Use at Initiation of Hemodialysis|
|#330||Adult Kidney Disease- Catheter Use for Greater Than or Equal to 90 Days|
|#343||Screening Colonoscopy Adenoma Detection Rate|
|#345||Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive|
|#346||Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive|
|#347||Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are Discharged Alive|
|#352||Total Knee Replacement- Preoperative Antibiotic Infusion with Proximal Tourniquet|
|#353||Total Knee Replacement- Identification of Implanted Prosthesis in Operative Report|
|#361||Optimizing Patient Exposure to Ionizing Radiation- Reporting to a Radiation Dose Index Registry|
|#362||Optimizing Patient Exposure to Ionizing Radiation- Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes|
|#371||Depression Utilization of the PHQ-9 Tool|
|#372||Maternal Depression Screening|
|#388||Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)|
|#403||Adult Kidney Disease- Referral to Hospice|
|#407||Appropriate Treatment of MSSA Bacteremia|
|#411||Depression Remission at Six Months|
|#417||Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where patients Are Discharged Alive|
|#428||Pelvic Organ Prolapse- Preoperative Assessment of Occult Stress Urinary Incontinence|
|#442||Persistence of Beta-Blocker Treatment After a Heart Attack|
|#446||Operative Mortality Stratified by the Five STS-EACTS Mortality Categories|
|#449||HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies|
|#454||Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life|
|#456||Proportion Not Admitted To Hospice|
|#467||Developmental Screening in the First Three Years of Life|
|#474||Zoster (Shingles) Vaccination|
CMS created Quality measure specialty sets made up of suggested measures per specialty. For 2020, CMS added seven new specialty sets:
- Speech language pathology
- Clinical social work
- Chiropractic medicine
If subspecialties do not have six applicable measures, they are required to submit all applicable measures in their specialty set—if a specialty set is available.
MIPS Quality Performance Category: Clinical Documentation Integrity and Audits
CMS initiated MIPS Data Validation Audits in June 2019. Auditors are provided with high-level supporting documentation guidelines that are based upon the MIPS quality measures specification documents. Data reported for each Quality measure will be reviewed for correct codes, patient age requirements, medications, and documentation supporting the submitted data.
Quality measure specifications have detailed requirements:
- Patient demographics
- Encounter CPT/HCPCS codes
- Procedure codes
- Encounter ICD-10-CM codes
- “Performance Met” and “Performance Not Met” requirements
- Denominator exceptions
- Denomination exclusions
- Reporting frequency
- Patient location at time of service
- Additional criteria as applicable
Practices are encouraged to carefully review the documentation and performance requirements for each Quality measure. Performance can be significantly improved if providers adequately document exclusion criteria, as exclusions remove the encounter from reporting.
For example, to meet the performance met requirement for MIPS CQM #005 “Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD),” the clinician needs to prescribe an ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting or at each hospital discharge. However, the measure specification states that the encounter is excluded from reporting if the clinician documents that the patient refused the medication. If this information is not documented, then the encounter would be scored as “performance not met.” This measure’s benchmark requires perfect performance for the practice to earn more than 6.9 points for the measure. If the one “performance not met” encounter can be removed from the denominator based on the exclusion (and supported by documentation), then the practice would receive a perfect 10-point score on the measure.
A significant number of Quality measure specification documents have nuances or ambiguities that must be addressed, frequently through extensive interactions with CMS. This emphasizes the importance of clinical documentation improvement (CDI) in MIPS Quality performance documentation and reporting.
As noted previously, practices that collect data using multiple EHR systems are required to aggregate data before it is submitted to CMS. This has created challenges for some practices. CMS stated in the 2020 PFS Final Rule that practices are required to inform CMS when the data they are submitting may not be complete or accurate. CMS also requires practices to retain data reported for MIPS for six years. Best practices include storing screenshots of quality actions in the EHR and performance dashboards, and any communications the practice may have had with CMS.
MIPS Quality Category Performance Strategy
Practices should review the specific details and requirements for all clinically applicable MIPS CQM, eCQM, Medicare Part B claims, and QCRD measures. Factors to consider include:
- Review MIPS specialty sets for potential measures
- Note the measure’s encounter or procedure demographic and coding requirements based on age, gender, numerator, and denominator requirements, including applicable ICD-10-CM, CPT, and HCPCS codes (depending on the measure) and denominator exclusions.
- Assess whether the measure has a current benchmark.
- Select at least one outcome measure, preferably with a benchmark. If no outcome measures are applicable, select at least one high-priority measure.
- Consider reporting as many outcome and high-priority measures as possible (to earn additional bonus points).
- Select as many measures as possible, weighted towards measures with benchmarks.
- If benchmarks are available:
- Is the measure score capped at 7 points?
- What performance rates are required to achieve a high score?
- Does the measure have benchmarks for more than one collection type?
- Identify if there is support within your EHR for data capture and reporting, including the use of eCQMs, MIPS CQMs, and QRDA measures.
- Determine if there is EHR vendor support for end-to-end electronic reporting.
- Identify challenges related to provider documentation and the need for further provider education or incentives.
- Review applicable QCRD measures for benchmarks and potential costs.
- Identify as many measures as possible that are applicable to the practice, preferably more than 10.
- Assess the CDI requirements for each measure and perform periodic spot-checking throughout the performance period.
- Implement a tracking process that can identify low performance for selected measures and perform root cause analysis and interventions as needed.
Michael Stearns ([email protected]) is the founder and CEO of Apollo HIT, LLC.
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