Quality measure performance rates are assessed against historical benchmarks, if available, to determine how many achievement points should be assigned for the measure. Benchmarks are categorized into deciles, based on actual performance data submitted to PQRS in 2016. Because of the variability of performance rates, a high performance rate for a given measure does not guarantee the maximum number of points for that measure.
It is important to note that if you submit more than the minimum number of required measures, CMS will select the top six measures, based on points, for you, along with any additional measures that may qualify for bonus points.[1] Therefore, the ACR recommends you submit as many measures as possible to maximize your points. This approach will also provide CMS with additional data that may be used for new benchmarks that better represent the range of performance across clinicians. The purpose of this article is to inform you of how CMS will perform the calculations; you are not expected to do these calculations prior to submitting your measures.
Quality measure performance rates are compared to benchmarks and assigned between 3 and 10 points each. In order for a measure to be benchmarked, each of the following must be true
A benchmark must be available
You must report on the minimum number of cases (>20 for most measures)
You must submit data on at least 60% of all cases for the period, not just Medicare patients.
If the above criteria are met, the measure can be reliably benchmarked and achievement points may be calculated. If any of the above criteria are not met for a measure for which data were submitted, then the clinician receives the minimum 3 points for that measure.
Each benchmark is presented in terms of deciles and points are awarded within each decile. For the 2018 performance year, performance rates that fall in the first or second decile receive 3 points. Performance rates in the third decile receive somewhere between 3 and 3.9 points depending on their exact position in the decile, and performance rates in higher deciles receive a corresponding number of points.
Single Measure Example
Suppose a clinician submits data yielding a performance rate of 83.0% on measure 145, Exposure Dose Time Reported for Procedures Using Fluoroscopy. The fourth decile ranges from 78.00% – 84.61%, so the clinician receives between 4 and 4.9 points because 83.0% falls in the fourth decile.
The precise calculation is determined by where the performance rate falls in the decile range, using the formula
decile + ( (p – a)/(b - a) )
where
decile = decile in which the performance rate falls
p = performance rate
a = lower end of decile
b = higher end of decile
The above example yields
4 + ( (83.0 – 78.0) / (84.61 – 78.0) ) = 4 + (5 / 6.61) = 4 + 0.7564 = 4.8
Decimal values between 0.0 and 0.89 are rounded to the nearest tenths place; values above 0.89 are truncated to 0.9.
Note: For inverse measures where positive performance is denoted by a lower number on the performance score, the scores are reversed in the benchmark deciles.
The measure may also receive bonus points, up to 10% of the maximum possible points. Bonus points may be achieved for either the six required measures or from any additional measures reported.
Overall Quality Performance Example
To calculate a clinician’s overall Quality Performance score, CMS will select the top six measures, plus any bonus points. At least one of the measures must be an Outcome measure, or, if one is not available for the clinician’s practice, at least one must be a High Priority measure.
For example, the table, below, shows the performance rates and points for nine QCDR and MIPS measures.
There are three outcome measures, so one is automatically selected to meet the minimum requirement.
The remaining measures are ranked by achievement points, with the top five selected to meet the minimum requirement of six measures. This yields a total of 35.3 points for all selected measures, before any bonus points.
Note: Measure 225 has only 3.1 achievement points because the benchmark deciles are significantly skewed toward the high end. CMS has decided to not change the calculation methodology for topped out measures in 2017. Therefore, the performance rate of 99.90 in this example falls into decile 3, which ranges from 98.89 to 99.99 points, yielding 3.1 achievement points. A performance rate of 100 would result in 10 points.
The High Priority / Outcome Bonus column denotes measures contributing bonus points – two points for each additional outcome measure, and one point for each High Priority measure, for a total of seven bonus points. However, the number of bonus points cannot be greater than 10% of the maximum possible points (60), so bonus points are capped at 6. In this example, the clinician gained a net of one bonus point from having submitted additional measures beyond the minimum requirement.
With bonus points, the total is 35.3 + 6.0 = 41.3 points out of a possible 60, yielding a Quality score of 68.8%.
Note: In cases where benchmarks are not available, CMS will create a benchmark using 2017 performance year data provided there are sufficient observations. Therefore, in this scenario, the final Quality score may be higher. For this reason, it is in the clinician’s best interest to report all measures, even there are no benchmarks currently available.
The Quality score calculated by CMS is weighted to determine how many points the category contributes to the MIPS final score.
[1] CMS MIPS and APM Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, 81 Fed. Reg. 77300 (Jan. 1, 2017)↩