Under the Medicare Access and CHIP Reauthorization Act (MACRA), the law signed in April 2015, 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).
Eligible clinicians must collect quality data for the entire calendar year (January 1, 2019-December 31, 2019).
Clinicians must report six measures, including one outcome measure. ECs can earn two bonus points for each additional outcome and patient experience measure reported and one bonus point for each additional high-priority measure reported. Bonus points are also available for measures reported using electronic end-to-end reporting (see below for details).
Small practices (15 or fewer ECs) that report at least one quality measure will receive six bonus points added to their quality performance category score.
Clinicians can report using claims (individuals and small practices), qualified registry, qualified clinical data registry (QCDR), electronic health record (EHR), or CMS Web Interface (for groups of 25+ ECs).
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.
For a measure to be scored based on performance for the 2019 performance period, clinicians must report on a minimum of 20 unique patients (except all-cause hospital readmission, which is 200; see below for details) and meet the data completeness criteria. The measure must also have a benchmark.
Data completeness criteria for 2019 requires reporting on at least:
Reporting the Consumer Assessment of Healthcare Providers and Systems (CAHPS) is optional.
In addition to the six self-reported measures, the Centers for Medicare & Medicaid Services (CMS) will calculate the all-cause hospital readmission measure for groups of 16 or more clinicians with at least 200 cases.
Each measure is worth up to 10 points. The maximum points available for the quality category depends on the clinician’s group size or submission mechanism.
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 two bonus points for each additional outcome and patient experience measure reported and one bonus point for other high-priority measures.
In addition to the bonus points outlined above, clinicians can earn one bonus point for each measure submitted with end-to-end electronic reporting.
For the measure to be scored on performance, it must have a benchmark and meet case minimum and data completeness criteria. Performance on a measure is compared to quality measure benchmarks that are based on historical performance data from two years prior (e.g., 2019 benchmarks are based on 2017 data).
Measures without a benchmark or do not meet case minimums will receive three points. In general, measures that do not meet data completeness will receive one point. However, small practices (15 or fewer ECs) will receive three points for all measures, including those that do not meet data completeness.
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.
SAMPLE QUALITY MEASURE BENCHMARKS
CMS began measuring quality improvement beginning with the 2018 performance period. Improvement is measured at the quality category level (vs. the quality measure level).
CMS calculates the percent change in performance from the previous performance period to the current performance period.
Eligible clinicians can earn up to an additional 10 percentage points towards their quality category score based on improvement.