Practice Scenario: Full Participation

Pick Your Pace

Practice Scenario: Full Participation

Pick Your Pace Practice Scenario #3: Full Participation

Dr. Meyer is a family physician in a medium-sized practice of 20 clinicians; is not part of an accountable care organization (ACO); and has participated in the Physician Quality Reporting System (PQRS), Medicare and Medicaid Electronic Health Records (EHR) Incentive Program (Meaningful Use), and the Value-based Payment Modifier (VBPM) program for several years. She wants to fully participate in the Quality Payment Program (QPP) using a qualified clinical data registry (QCDR). She’s participated in a QCDR for the last two years and has invested resources to map data from her EHR to the QCDR. Her EHR is 2014 certified. How should she begin participating in QPP?


Dr. Meyer can avoid a 2019 negative payment adjustment and potentially earn a modest positive payment adjustment by meeting all of the Merit-based Incentive Payment System (MIPS) reporting requirements using the QCDR. Dr. Meyer follows these steps:

1. Dr. Meyer contacts her QCDR vendor and verifies that it is qualified as a MIPS QCDR for 2017. She verifies that the QCDR has the ability to submit data and is ready for full reporting for three of the MIPS performance categories (quality, improvement activities [IAs], and advancing care information [ACI]. The fourth performance category, which is cost, requires no data submission.

2. Dr. Meyer obtains the list of available measures and measure specifications from her QCDR vendor. She and her vendor confirm at least six of the measures she reported in the past are still offered, and at least one of the measures is an outcome measure.

3. Dr. Meyer received an end-of the-year report from her QCDR for 2015. She verifies the numerators, denominators, exclusions, and performance rates for her 2015 measures are correct. She also reviews her performance compared to the benchmark and determines she is doing better than average, but there is room for improvement. If she finds any data that appears inaccurate, she works with her QCDR and staff to determine the cause of the inaccuracy. For example, incorrect or incomplete coding, undocumented care, missing results from other clinicians, or incorrect mapping between the EHR and QCDR, which may lead to inaccuracies in the data. She implements interventions to address data inaccuracies.

4. Dr. Meyer and her staff develop care protocols, adopt templates, and establish efficient workflows to meet evidence-based guidelines, which allow them to quickly document data as needed for their quality measures.

5. As the office closes each night, data is automatically transmitted to the QCDR.

6. The QCDR generates monthly feedback reports, which Dr. Meyer and her staff review as a team. They set aside time each month to look for inaccuracies, analyze their comparative performance, and discuss opportunities to improve care. They test interventions throughout the year, and when appropriate, involve patients in their discussions.

7. At the end of the year, the QCDR submits data to the Centers for Medicare and Medicaid Services (CMS) for quality measures, improvement activities, and ACI measures. Since Dr. Meyer and her staff have worked continuously throughout the year on quality reporting and improvement, there is no end-of-the-year rush to report to MIPS.


To fully participate in MIPS with a QCDR, Dr. Meyer must:

1. Report at least six quality measures, including at least one outcome measure, for a minimum of 90 days (up to a full year), and meet the data completeness criteria.* If she reports more than six quality measures, CMS will use the six with the highest performance to calculate her quality score.

2. Complete up to four activities (a combination of medium- and high-weighted activities) in the improvement activities category. Each activity must be performed for at least 90 consecutive days during the performance period to earn points. If Dr. Meyer’s practice is a “certified” or “recognized” patient-centered medical home (PCMH), it automatically receives full credit for the IA category.

  • Several improvement activities are related to participation in a QCDR, which the physician may already be performing. These may include:
    • Leveraging a QCDR to standardize processes for screening for social determinants of health, such as food security, employment, and housing.
    • Using a QCDR for feedback reports that incorporate population health.
    • Using QCDR patient experience data to inform and advance improvements in beneficiary engagement.
    • Using QCDR data to support shared clinical decision making.

3. Report on required ACI measures( to earn a base score, AND include additional performance measures for a continuous 90-day period in 2017.

*Data completeness for the QCDR reporting method is 50% of all denominator-eligible patients seen during the performance period, regardless of payer.

Dr. Meyer is not required to report the same 90-day period for each performance category. For example, she can report quality for the first quarter and focus on her improvement activities in the second quarter.

Earning Additional Points

Dr. Meyer could improve her MIPS final score by working throughout the year to raise her performance rates as high as possible on quality and ACI measures. There is also an opportunity to earn bonus points under both the quality and ACI categories. Finally, she might consider participating in an Advanced Alternative Payment Model (AAPM) to potentially become eligible for AAPM bonuses and increase her annual Medicare fee schedule updates (beginning in 2026).

Other Reporting Options

Physicians can fully participate using any of the reporting options: claims, qualified registry, EHR-based reporting, or the Web Interface (if reporting as a group of 25 or more clinicians). Although her QCDR can report to all MIPS performance categories, Dr. Meyer can use different reporting methods for different categories. However, she must use one data submission mechanism per performance category. Since Dr. Meyer has already invested in QCDR participation, this is the most feasible course for participation in MIPS. QCDRs have the added advantage of offering more flexible quality measures and continual support of quality improvement efforts.

Preparing for the Future

Physicians that are participating in the QPP can stay up-to-date with all aspects of the program, including new opportunities for participation by bookmarking the AAFP MACRA Ready resources webpage.