Quality Performance Category

MIPS: Explaining the Quality Performance Category

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).

With the MIPS track, ECs receive a final score based on performance in four performance categories: quality, cost, promoting interoperability (PI), and improvement activities.

Quality Reporting

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).

• When reporting using the CMS Web Interface, clinicians must report on all CMS Web Interface measures.
• Beginning in 2019, the CMS Web Interface can only be used for the quality category.
  

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:

• Claims – 60% of Medicare Part B patients eligible for the measure
• EHR, qualified registry, or QCDR – 60% 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, 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.  

• 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, or 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.

Quality Scoring

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.

• 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 readmission 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 two bonus points for each additional outcome and patient experience measure reported and one bonus point for other high-priority measures.

• Other high-priority measures are defined as: appropriate use, patient safety, efficiency, care coordination, and opioid-related 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 one bonus point for each measure submitted with end-to-end electronic reporting.

• End-to-end electronic reporting means the MIPS-eligible clinician:
  • 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).

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).

• 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.
• Separate benchmarks are developed for each reporting method.  

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.

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.