Quality

MIPS Payment Track:

Quality Performance Category

MIPS: Explaining the Quality Performance Category

The Medicare Access and CHIP Reauthorization Act (MACRA) was passed and signed into law in April 2015. Under MACRA, eligible clinicians (ECs) will participate in either the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (AAPM). MIPS and AAPMs are collectively referred to as the Quality Payment Program (QPP).

With the MIPS track, ECs receive a final score based on performance in four performance categories: quality, cost, advancing care information (ACI), and improvement activities (IA).

To give ECs more time to learn about and adjust to QPP, the Centers for Medicare & Medicaid Services (CMS) deemed 2017 a transition year to “Pick Your Pace.”

Quality Reporting

For full participation in Pick Your Pace, clinicians must report six measures, including one outcome measure. Other options exist under Pick Your Pace (test and partial participation), which require reporting fewer measures to report.

All measures have a 20-patient case minimum (except all-cause hospital readmissions, which is 200; see below for details).

Clinicians can report using claims, qualified registry, qualified clinical data registry (QCDR), electronic health record (EHR), or CMS Web Interface.

  • Clinicians can only use one reporting method per performance category (i.e., they cannot report quality measures using claims and a qualified registry).
  • When reporting using the CMS Web Interface, clinicians must report on all CMS Web Interface measures.

If choosing to report as a group, all performance categories must be reported and will be scored as a group.

If reporting as a group, all clinicians within the group must report on the same measures.

As part of Pick Your Pace, all measures reported for the 2017 reporting period will receive a baseline of 3 points, regardless of performance.

In order for the measure to be scored based on performance for the 2017 performance period, clinicians must report on a minimum of 20 unique patients and meet the data completeness criteria.

Data completeness criteria for 2017 requires reporting on at least:

  • Claims – 50% of Medicare Part B patients eligible for the measure
  • EHR, qualified registry, or QCDR – 50% of all measure-eligible patients, regardless of payer
  • CMS Web Interface – all 248 consecutively ranked assigned Medicare beneficiaries; if less than 248 beneficiaries are assigned, the group must report on 100% of the beneficiaries listed

Reporting the Consumer Assessment of Healthcare Providers and Systems (CAHPS) is optional.

  • CAHPS counts as one quality measure. If reporting CAHPS, it’s permissible to use one other reporting mechanism to report the remaining measures.

In addition to the six self-reported measures, CMS will calculate the all-cause hospital readmission measure for groups of 16 or more clinicians with at least 200 cases. Performance on this measure has been included in the Quality and Resource Use Report (QRUR).

  • This measure evaluates the readmission rate for beneficiaries 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge.
  • Attribution for this measure uses a two-step method:
    • (1) A beneficiary is attributed to a tax identification number (TIN) if the beneficiary received more primary care services from primary care physicians, nurse practitioners, physician assistants, clinical nurse specialists within that TIN than from clinicians in any other TIN
    • (2) If a beneficiary cannot be attributed to a TIN using the first step, the beneficiary will be attributed to a TIN if they received more primary care services from specialist physicians within the TIN than from clinicians in any other TIN.

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Quality Scoring

The maximum points available for the quality category depends on the clinician’s group size or submission mechanism.

  • Groups of 1-15 ECs: 6 measures x 10 points per measure = 60 points
  • Groups of 16+ ECs: 6 measures x 10 points per measure + all-cause hospital readmissions x 10 points = 70 points
  • CMS Web Interface: 11 measures x 10 points per measure + all-cause hospital readmissions x 10 points = 120 points

If a clinician reports more than six quality measures, CMS will use the six with the highest performance to calculate the quality score.

Clinicians can earn 2 bonus points for each additional outcome and patient experience measure reported and 1 bonus point for other high-priority measures.

  • Other high-priority measures are defined as: appropriate use, patient safety, efficiency, and care coordination measures.
  • Bonus points are capped at 10% of the total quality score.
  • For most clinicians (those not reporting using the CMS Web Interface), this means the bonus points will be capped at 10% of the 60-70 points available in the quality category (i.e., 6-7 points).

In addition to the bonus points outlined above, clinicians can earn 1 bonus point for each measure submitted with end-to-end electronic reporting.

  • End-to-end electronic reporting means the MIPS EC:
    • Uses certified electronic health record technology (CEHRT) to record the measure’s demographic and clinical data elements;
    • Exports and transmits measure data electronically to a third party, or a third-party intermediary (e.g., QCDR); and
    • The third-party intermediary uses automated software to aggregate data, calculate measures, and submit electronically to CMS.
  • Bonus points are capped at 10% of the total quality category score.
  • For most clinicians (those not reporting using the CMS Web Interface), this means the bonus points will be capped at 10% of the 60-70 points available in the quality category (i.e., 6-7 points).

Performance on a measure is compared to quality measure benchmarks that are based on historical performance data from two years prior (e.g., 2017 benchmarks are based on 2015 data).

  • A benchmark is the historical performance on a quality measure, which ECs will be compared against.
  • For a measure to receive a benchmark, it must have a minimum of 20 ECs or groups who reported the measure, meet data completeness and case minimum requirements, and have a performance rate (i.e., the measure receives a performance score), which is greater than zero.
  • New measures without a previously published benchmark will receive 3 points.
  • Separate benchmarks are developed for each reporting method.

Measure benchmarks will be broken in to performance deciles. An EC’s performance will be compared to the benchmark and assigned points based on a sliding scale. Each measure is worth a maximum of 10 points.

Based on the hypothetical benchmark deciles below, a performance rate of 79% would receive 9.0 points towards the clinician’s quality score.

Benchmark Decile

Sample Quality Measure Benchmarks

Points Possible

Benchmark Decile

:

Decile 1

Sample Quality Measure Benchmarks

:

0.0-9.5%

Points Possible

:

3.0

Benchmark Decile

:

Decile 2

Sample Quality Measure Benchmarks

:

9.6-15.7%

Points Possible

:

3.0

Benchmark Decile

:

Decile 3

Sample Quality Measure Benchmarks

:

15.8-22.9%

Points Possible

:

3.0-3.9

Benchmark Decile

:

Decile 4

Sample Quality Measure Benchmarks

:

23.0-35.9%

Points Possible

:

4.0-4.9

Benchmark Decile

:

Decile 5

Sample Quality Measure Benchmarks

:

36.0-40.9%

Points Possible

:

5.0-5.9

Benchmark Decile

:

Decile 6

Sample Quality Measure Benchmarks

:

41.0-61.9%

Points Possible

:

6.0-6.9

Benchmark Decile

:

Decile 7

Sample Quality Measure Benchmarks

:

62.0-68.9%

Points Possible

:

7.0-7.9

Benchmark Decile

:

Decile 8

Sample Quality Measure Benchmarks

:

69.0-78.9%

Points Possible

:

8.0-8.9

Benchmark Decile

:

Decile 9

Sample Quality Measure Benchmarks

:

79.0-84.9%

Points Possible

:

9.0-9.9

Benchmark Decile

:

Decile 10

Sample Quality Measure Benchmarks

:

85.0-100%

Points Possible

:

10