The MIPS Quality category makes up 30 points of a clinician’s total MIPS score. Quality is reported for the whole year, and a clinician must report a minimum of six Quality measures to meet MIPS reporting requirements.  Data completeness remains at 70%.

A high Quality score is vital for avoiding the negative penalty deductions, with the increase in the performance threshold to 75 points making them harder to avoid. An efficient and high scoring Quality strategy is imperative for MIPS success this year.  Let’s take a look at some important points every clinician must factor into their Quality strategy.

• Avoid topped out measures

The Centers for Medicare & Medicaid Services (CMS) defines a topped-out measure as one whose median performance score is 95% or “so high and unvarying that meaningful distinctions and improvement in performance can no longer be made.”  Topped out measures are reported by a large number of MIPS clinicians with very high performance. CMS deems that continuous reporting of these measures will not result in collection of meaningful Quality data and provide clinicians opportunities to improve the quality of care they provide to patients.

The CMS places a cap of 7 points on topped out measures, rather than 10 points, even if their performance rate is 100%. Topped out measures must be reported on applicable patients of all insurances like all CQM (Registry) measures. Topped out measures are eventually removed from MIPS following a 4 year cycle.  If a measure has been topped out for 3 consecutive years it will be removed in the next year (4^th year). Certain topped out measures may not follow the 4 year cycle, and may be removed sooner.

If a clinician chooses to report six topped out Quality measures, the maximum score attainable will be 42 points, losing out on 18 potential points that could have been obtained if other measures were reported; a 30% loss in points. This year, with the minimum performance threshold set at 75 points, every point matters, and reporting topped out measures this year is a very risky strategy, with how challenging MIPS has become.  Measures with 10 point benchmarks must be prioritized over topped out measures to ensure maximum Quality score.

• Choose measures with efficient benchmarks

Quality measure benchmarks define the points a performance rate can reap for a measure. Quality measures can earn 0-10 points. Let’s take a look at benchmarks for two measures; Diabetes Eye Exam and Colorectal Cancer Screening.

Diabetes Eye Exam

Decile 3	Decile 4	Decile 5	Decile 6	Decile 7	Decile 8	Decile 9	Decile 10
94.31-97.85	97.86-99.32	99.33-99.85	99.86-99.99	100	—	—	—

For Diabetes Eye Exam, a performance rate of 100% yields 7 points, with a rate of 99% yielding just 4 points. A 1% drop in performance rate leads to an immense 42% drop in points. A performance rate below 94.31% provides no points.

Colorectal Cancer Screening

Decile 3	Decile 4	Decile 5	Decile 6	Decile 7	Decile 8	Decile 9	Decile 10
17.93-34.79	34.80-51.80	51.81-61.05	61.06-74.18	74.19-82.03	82.04-92.40	92.41-99.42	>=99.43

 

For Colorectal Cancer Screening, a performance rate of 99.43% yields 10 points, with a rate of 99% yielding 9 points for the measure. A performance rate below 17.93% provides no points.

When comparing both measures, you can see for Diabetes Eye Exam a small drop in performance rate leads to a substantial drop in points. Even a performance rate as high as 94% will yield no points, but the rate yields 9 points for Colorectal Cancer Screening. This shows that diabetes eye exam is an inefficient measure in terms of scoring points, with clinicians facing a disproportionate drop in points when their performance rate falls. Measures with benchmarks similar to Diabetes Eye Exam should be avoided when reporting Quality this year.

• Choose measures with small patient population

Certain Quality measures require a large patient population be reported. For example, for Quality Measure Preventive Care and Screening Influenza Immunization, patients of the age of 6 months and greater of all genders must be reported. On the other hand, for Breast Cancer Screening only female patients between the ages of 51-74 must be reported.

The patient population for Breast Cancer Screening is far smaller in comparison to Influenza Immunization. A measure with a small patient population translates to less work for the reporting clinician, and can still earn the maximum 10 points.

A measure with a smaller patient population also has a lower chance of a decrease in performance rate. A Quality measure has a performance met option which increases its performance rate, and a performance not met option which decreases its performance rate. When data completeness has been met, the number of instances performance not met has been reported decreases its performance rate.  A lower performance rate yields fewer points. With fewer patients having to be reported for a measure, there is a lower possibility of performance not met being reported for a patient. Let’s take a look at the reporting options for Quality ID #112 (NQF 2372): Breast Cancer Screening.

• Screening, diagnostic, film, digital or digital breast Tomosynthesis (3D) mammography results documented and reviewed (Performance Met)
• Screening, diagnostic, film, digital or digital breast Tomosynthesis (3D) mammography results were not documented and reviewed, reason not otherwise specified (Performance Not Met)

When data completeness has been met, the number of instances of “Screening, diagnostic, film, digital or digital breast Tomosynthesis (3D) mammography results documented and reviewed” is reported for Quality Measure 112, increasing its performance rate. On the other hand, the number of times “Screening, diagnostic, film, digital or digital breast Tomosynthesis (3D) mammography results were not documented and reviewed, reason not otherwise specified” is reported decreases the performance rate.

The performance not met option for Breast Cancer Screening is reported when the clinician hasn’t documented a mammography for the patient. If Breast Cancer Screening had a patient population similar to Preventive Care and Screening Influenza Immunization, it’s likely it would have a lower performance rate. A larger patient population requires a higher number of patient encounters be reported. With fewer patients, the probability of reporting performance not met decreases. Which favors a high performance rate, yielding more points for the measure.

 

Measures with smaller patient populations should be prioritized over those that have larger patient populations. A lower work burden for Quality allows clinicians to focus on other MIPS categories to make improvements to their total score. This is a big advantage for small practices eligible to report MIPS, because with their limited resources they aren’t able to dedicate the time and practice staff like large practices to maximize their score. With less work needed for MIPS, it allows the clinician and practice staff to allocate more resources to other areas such as making improvements to the quality of patient care.

Clinicians must consider the three factors mentioned above when selecting Quality measures to report for MIPS this year. Doing so will lead to a successful Quality strategy, gaining clinicians the maximum points. A high score this year isn’t just about avoiding the penalty deduction, but also becoming eligible to earn the largest bonus payout for MIPS since the program started.

CureMD’s MIPS consultants are experts in developing and implementing a high scoring and efficient Quality strategy. With nearly 200 Quality measures to choose from, reviewing measure specifications and benchmarks can be overwhelming.  With over a decade of experience working with CMS incentive programs and in depth knowledge of Quality measures, our consultants will have you on track to attain the maximum points for the Quality category with little work burden.

Keeping track of measure progress is burdensome and taxing. Our consultant will be your guide for the whole year. Routine follow ups are scheduled with clinicians to make sure they are on track to meet performance goals. We provide detailed progress reports during each follow up, explaining total Quality score, performance rate for each measure, verification data completeness, and a plan for continued Quality success for the whole year. Clinicians working with us have access to our state of the art MIPS dashboard that provides real time updates about MIPS progress throughout the whole year. With a 100% success rate and over 18,000 quality submissions our consultants are experts at maximizing Quality scores.

To learn more about MIPS and how a CureMD consultant can help you click here.