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Understanding the MIPS Quality Component Score

The Medicare Quality Payment Program has officially launched, meaning most physicians (and most non-physician practitioners) now are in the initial performance period under the Merit-Based Incentive Payment System (MIPS). With 60 percent of the MIPS composite score based on a physician’s performance on quality measures, the selection of the most appropriate measures and the manner in which to report on those measures is critical.

MIPS quality reporting requirements

To maximize one’s quality component score, a physician must report individually or as part of a group on a minimum of six measures from the nearly 300 MIPS-approved measures, at least one of which must be an outcome measure. (Physicians who participate in the Medicare Shared Savings Program are subject to different requirements.) A physician or group may report on more than six measures, in which case CMS will use the six measures with the highest scores to calculate the component score.

Specialty measure sets

CMS has attempted to streamline measure selection by publishing 30 specialty-specific measure sets.  For most physicians, these measure sets are advisory only. A medical oncologist, for example, may select from the 19 measures included in the medical oncology measure set or choose to report on other MIPS-approved measures. For those measure sets that include fewer than six measures — such as the radiation oncology measure set — a specialist need only report on those measures to receive full credit.

Data completeness

Under MIPS’ predecessor, the Physician Quality Reporting System (PQRS), most physicians reported data on a small subset of patients. With MIPS, however, a physician or group must report data on at least fifty percent of their relevant patient population (unless reporting through the CMS Web Interface).

Reporting methods

Table 1 summarizes the methods by which physicians and groups may report on and corresponding measure and data completeness requirements.

Table 1: Reporting requirements for MIPS quality component

Manner of participation

Submission type

Measure requirements

Data completeness

Individual

Part B claims

6 measures (at least 1 outcome measure) OR specialty-specific measure set

50% of Part B patients (60% in 2018)

Individual or group

QCDR, qualified registry, or EHR

6 measures (at least 1 outcome measure) OR specialty-specific measure set

 

50% of individual's or group's patients who meet measure denominator (60% in 2018)

Group

CMS web interface (register by 06/30/17)

All measures (15) included

 

CMS-selected sampel of Part B patients

Three interrelated decisions:  individual vs. group reporting, measure selection, and reporting method selection

There are three key decisions a physician must make with regard to MIPS quality reporting: 

  1. Whether to report individually or as part of a group.
  2. Which quality measures on which to report.
  3. What method to use in reporting data to CMS.

1. Group vs. individual reporting
Group reporting has the advantage of reducing the administrative burden associated with data collection and submission. However, group reporting is an all-or-nothing proposition. First, all three components (quality, advancing care information, and clinical practice improvement activities) must be reported at the group level. 

Second, all physicians and non-physician practitioners who are part of the group must be included in the group’s reporting. For example, a six-physician group cannot have four physicians report as a group and the other two report individually. As a result, each group member will have the same MIPS composite score if group reporting is selected, regardless of one’s individual performance. Thus, there is the risk a group’s top performers will be penalized due to others’ poor performance. 

Also, keep in mind that only individuals may report via Part B claims, and only groups with 25 or more providers may report using the CMS claims interface. As discussed below, separate benchmarks are calculated for the same measure based on the reporting method used. Thus, it may be advantageous to report individually if the Part B claims benchmark is more favorable for selected measures.    

2. Measure selection
Impact on workflow
In many cases, some workflow adjustments will be necessary to maximize a physician’s score on a particular measure. One should consider the potential impact on workflow in selecting measures; making too many changes at once may undermine success. 

3. Method of reporting
Regardless of whether reporting individually or as a group, data on all measures must be submitted using the same method:  Part B claims, registry, electronic health record or CMS web interface.  While registry reporting is available for all MIPS-approved measures, the other reporting methods are more limited in scope. Take, for example, the measures included in the oncology measures sets:, as shown below in Table 2.  

Table 2: Number of reportable measures (% of total) by submission type)
Submission type General oncology specialty set Radiation oncology specialty set
Part B claims 7 (37%) 1 (25%)
Registry 18 (95%) 4 (100%)
EHR 6 (32%) 2 (50%)
  Total measures 19 4

Source: 2017 MIPS quality measures as available on qpp.com.cms.gov
Note: some measuers allow more than one submission type

In the case of radiation oncologists, a physician faces a choice:  report data via a registry (as this is the only option that covers all four measures in the measures set) or report on six measures, including measures outside the radiation oncology specialty measure set.  

Prior reporting
Under PQRS, the primary consideration in selecting measures was the ease with which one could collect and report data for a given measure. Under MIPS, however, the object of the game is maximizing a physician’s or group’s score on a given measure. While the ability to collect and report data remains important, the key consideration now is the ability to achieve a higher performance percentage on a specific measure. Thus, simply sticking with the measures one already knows may prove unwise. 

Outcome measures
As noted above, at least one of the six measures on which an individual or group reports must be an outcome measure. There are three outcome measures included in the medical oncology specialty measure set, and all three are limited to registry reporting.  Thus, an oncologist who wants to report data using another method will have to select a different outcome measure on which to report. 

The radiation oncology measure set does not include an outcome measure. However, if a radiation oncologist reports on the four measures in the set, he or she will be excused from the outcome measure requirement.

Optimizing quality scores

As noted above, an individual’s or group’s MIPS composite score depends in large part on the individual’s or group’s scores on selected quality measures. Under MIPS, these scores are calculated by comparing the physician’s or group’s score on each individual measure to historical benchmarks. Under the regulations, CMS is required to calculate those benchmarks annually based on how physicians using the same submission method scored on that measure during prior reporting periods, and then publish those benchmarks prior to the beginning of the performance period. Stated another way, each measure has up to four separate historical benchmarks, one for each method by which the measure has been reported previously (i.e., Part B claims, EHR, registry, or CMS web interface).

CMS reports the benchmarks as deciles, and a physician or group earns a specified number of points (between 0 and 10) depending on the decile into which their score falls. For example, an eligible clinician with a 19 percent performance rate would receive approximately 3.3 points, based on a distribution within the third decile of 3.0-3.9. An eligible clinician with a 95 percent performance rate would receive the full 10 points. 

On December 28, 2016, CMS released the 2017 quality measure specifications (i.e., numerators and denominators) and benchmarks for all of the nearly 300 MIPS quality measures. With this information now available, physicians can make informed decisions regarding MIPS quality reporting.

Take, for example, the measure for “Oncology: Medical and Radiation – Pain Intensity Quantified,” which requires physicians to quantify pain intensity for all diagnosed cancer patients currently receiving chemotherapy or radiation therapy. For this measure, an individual or group may report using their EHR or through a registry. As demonstrated by Table 3, however, the benchmarks for this measure vary significantly based on the data submission method:  

Table 3: Sample quality measure and performance thresholds
Measure name Submission method Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10 Topped out
Oncology: medical and radiation - pain intensity quantified (#143) EHR -- -- -- -- -- -- -- 100 Yes
Registry/QCDR 35.53-76.18 76.19-82.13 82.14-90.20 90.21-96.76 96.77-99.99 -- -- 100 No

Source: CMS Quality Measure Thresholds for 2017 MIPS Reporting (qpp.cms.gov)

If reporting data on this measure via EHR, an individual or group will receive zero points on this measure absent a perfect rate of performance. By comparison, those reporting data through a registry can receive up to seven points for less-than-perfect performance. 

Not every benchmark favors registry reporting over EHR; in some cases, the opposite is true.  The 2017 quality measure benchmarks are full of discrepancies by submission method, just like this example.

Some measures, including the previous example, are “topped out” – meaning there is little difference between the worst and best performers on the measure. Once a measure tops out, it is on the short road to retirement, as there is no longer an opportunity for improvement in the performance it measures. It is very difficult for physicians to earn high scores when reporting these “topped out” measures.

As the pain intensity measure demonstrates, a measure may be topped out if reported in one way, but not others. Table 4 and Table 5 present information about the topped out measures in the General Oncology and Radiation Oncology measure sets by submission type.

Table 4: Topped out measures by reporting mechanism, general oncology set
Submission type Total benchmarked measures Topped out measures Topped out percentange
Claims 5 3 60%
EHR 5 2 40%
Registry/QCDR 7 1 14%

Source: CMS Quality Measure Thresholds for 2017 MIPS Reporting (qpp.cms.gov)

Table 5: Topped out measures by Reporting mechanism, radiology oncology Set
Submission type Total benchmarked measures Topped out measures Topped out percentange
Claims 0 0 -
EHR 1 1 100%
Registry/QCDR 4 1  

Source: CMS Quality Measure Thresholds for 2017 MIPS Reporting (qpp.cms.gov)

For these measure sets, claims and EHR measures have higher topped out percentages than registry reporting. This is just another factor to consider when choosing individual measures and submission method.

Calculating the quality component score

In addition to earning points on the six reported quality measures (or receiving a zero score on each unreported measure), CMS also will score an individual or group on a seventh quality measure – all-cause readmissions – using claims data. However, CMS will not calculate this score if the individual or group has fewer than 200 hospital admissions during the relevant time period. 

In addition, an individual or group has the opportunity to earn bonus points. One additional point is available for each measure reported using CEHRT for end-to-end electronic reporting, up to 10 percent of total possible points.  An individual or group can earn two bonus points for reporting additional outcome or patient experience measures (beyond the one required measure), and one bonus point for reporting on other high priority measures, up to 10 percent of total possible points.   

Timing

Across all MIPS components, physicians have timing and participation flexibility for meeting MIPS requirements in 2017. CMS considers 2017 a transition year during which physicians can meet lesser requirements for shorter periods of time – a minimum of 90 days – to avoid any financial penalties. Thus, physicians still have sufficient time to evaluate and select quality measures, and to implement performance improvement initiatives to improve scores on those measures.

The first performance year, 2017, remains an excellent opportunity for physicians to attempt to meet full requirements with little downside (time and effort) and the potential for significant financial upside (up to +12 percent of base FFS payments in 2019).