MIPS Manual 2017—Quality: How You’ll Be Scored

This content was excerpted from EyeNet’s MIPS Manual 2017.

Scoring—In 2017, Quality Measures Have a Floor of 3 Points

For each quality measure that you report, you get at least 3 points. In MIPS’ inaugural year, to reduce your financial risk as you transition to this new payment system, CMS has set a floor of 3 points for every quality measure that you report—even if the case minimum requirement (20 patients) and data completeness criteria (50% of applicable patients over at least 90 days) are not met (see “Meet Quality’s Submission Thresholds”).

The floor may drop in 2018. In the proposed rule for 2018, clinicians in small practices (with 15 or fewer MIPS eligible clinicians) who fail to meet the data completeness threshold (see “Meet Quality’s Submission Thresholds”) for a quality measure will continue to score 3 points, but others will have a 1-point floor.

Scoring—Your Performance Rate Will Be Compared Against a Benchmark

For the 2017 performance year, a measure’s benchmark will typically be based on performance data from 2015. However, if a measure didn’t exist in 2015, its benchmark will be based on data from the 2017 performance year. In either case, the benchmark will be based on performance data drawn from all clinicians who use the measure.

How to score more than 3 points for a measure. Provided that a measure has a benchmark for the reporting mechanism that you are using, you can attain 3-10 points if you meet the data submission thresholds.

Your score (3-10 points) will depend on how your performance compares against a benchmark. There are separate benchmarks for claims-based reporting, for reporting via manual data entry into a registry portal, and for EHR-based reporting (whether via IRIS Registry integration or via your EHR vendor). These benchmarks are based on data from 2015.

Each benchmark is broken into deciles, and the number of points you receive will depend on which of those deciles you fall into:

• If you fall within the first 2 deciles, you will receive 3 points. (This is because MIPS measures have a floor of 3 points during the 2017 performance year.)

• If you fall in deciles 3 through 9, you will receive partial points depending on where you fall within that decile. (For instance, if you fall in the ninth decile, you could receive 9.0-9.9 points.)

• If you fall within the tenth decile, you’ll receive the full 10 points.

Benchmarks are online. You can download a CMS spreadsheet that provides benchmark data for all the MIPS quality measures: Go to https://qpp.cms.gov/about/resource-library and download “2017 Quality Benchmarks.” The Academy also has posted some of those benchmarks at aao.org/practice-management/regulatory/mips/quality-reporting-measures.

Table 14: Benchmarks for Scoring Quality Measure 12—POAG: Optic Nerve Evaluation

The charts below illustrate how your score for a quality measure— in this case measure 12—will be based on how your performance rate compares to a benchmark. For this measure, the performance rate represents “the percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during 1 or more office visits within 12 months.”

Table 14A: Reporting by Claims

Table 14B: Reporting by IRIS Registry/ EHR Integration or EHR Vendor

Table 14C: Reporting by IRIS Registry Web Portal

Scoring—Watch for Measures That Don’t Yet Have Benchmarks

If a measure lacks sufficient performance data for a benchmark, you can’t score more than 3 points. CMS won’t assign a measure a benchmark unless it has enough data. The performance data that it is using to set the benchmark must include data from a minimum of 20 individual clinicians or groups that met the data submission thresholds and had a performance greater than zero. With an established measure, you will know in advance whether it has a valid benchmark and whether its benchmark is topped out; but with a new measure, you won’t know that until the performance year is over.

If you plan to report a measure that does not yet have a benchmark, you should also report a back-up measure. If a measure does not yet have a benchmark, there is a chance that, when the benchmark is developed, the measure might be topped out—which could limit your ability to score highly. There is also the danger that the measure is reported by fewer than 20 MIPS participants, in which case CMS wouldn’t have enough data to develop a benchmark.

Scoring—Watch for Measures That Are Topped Out

Some benchmarks reach, or almost reach, the maximum performance value well before the tenth decile. These are known as topped out measures.

Topped out measures can be hazardous to your quality score. When a measure is topped out, you will need a perfect performance rate to score 10 points. If your performance is less than perfect, there would be a ceiling on your maximum score—for example, with measure 12 (see Table 14), the ceiling would be 3.9 points for claims-based reporting and 5.9 points if reporting via the IRIS Reqistry web portal.

Bonuses for High-Priority Measures and CEHRT

For each quality measure, you can score up to 10 points based on performance, but you can also score additional bonus points.

Bonus points for reporting high-priority measures. You get no bonus points for your first high-priority measure, but after that you get:

• 2 points for an outcome or patient experience measure.

• 1 point for an appropriate use, care coordination, efficiency, or patient safety measure.

Why you don’t score bonus points for your first high-priority measure. There is no bonus point for the first high-priority measure because you are required to report at least 1 outcome measure (or, if no outcome measure is available, an alternative high-priority measure). You are eligible for bonus points even if you report fewer than 6 measures.

Bonus points for using certified EHR technology (CEHRT). You also can earn 1 bonus point for each measure that is submitted using “end-to-end electronic reporting” by means of CEHRT. This can include measures reported via IRIS Registry/EHR integration or your EHR vendor.

You can score up to 12 (or 14) bonus points. Your high-priority and CEHRT bonuses are each capped at 6 points or—if you are a large practice that is scored on the ACR measure (see “The All-Cause Hospital Readmission (ACR) Measure for Larger Practices”)—7 points.

How CMS Calculates Your Quality Score

This is a 3-step process:

1) CMS determines your numerator, which is your total points earned (including bonus points) on up to 6 reported measures plus—if applicable—your score for the ACR measure (this population measure only applies to large practices).

2) CMS divides that numerator by your denominator, which is 60 (or 70 if the ACR measure applies).

3) CMS turns the resulting fraction into a percentage, which is capped at 100%. This is your quality performance score.

Example. Suppose you report only 4 measures and your total score for those measures (including bonus points) is 30 points. The ACR measure applies, and you receive 5 points for that. Your numerator (total score) is 35, your denominator is 70, and your quality performance score is 50% (35/70).

Your quality score (0%-100%) contributes up to 60 points to your MIPS final score. For example, if your quality score was 50%, it would contribute 30 points (50% of 60) to your MIPS final score.

Need Help Selecting Your Measures?

Which measures have no benchmarks? Which are topped out? And which are high priority measures? Download 2 PDFs that provide all that information at a glance: Table 15: 31 Quality Measures and Table 16: 23 Non-MIPS (QCDR) Quality Measures.

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Next: Quality: How to Avoid the Payment Penalty

Note: Meeting regulatory requirements is a complicated process involving continually changing rules and the application of judgment to factual situations. The Academy does not guarantee or warrant that regulators and public or private payers will agree with the Academy’s information or recommendations. The Academy shall not be liable to you or any other party to any extent whatsoever for errors in, or omissions from, any such information provided by the Academy, its employees, agents, or representatives.

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