What is the Quality Performance Category?

Description

The Quality performance category is the MIPS replacement for PQRS. Its purpose is to encourage providers to perform clinical activities that will improve the quality of care.

The Quality category requires providers to report on six (6) standardized quality measures in 2017. There are hundreds of measures to choose from, and most are identical (or nearly so) to those that were available under PQRS. There are six types of measures. They are:

  • Efficiency
  • Intermediate Outcome
  • Outcome
  • Patient Engagement/Experience
  • Process
  • Structure

Some measures are designated high priority measures. The six (6) selected measures must include at least one measure that is an outcome measure and/or a high priority measure.

There are several important differences between MIPS Quality and PQRS. The two most significant differences are:

  • Measures Group reporting with a 20-patient sample is no longer permitted.
  • For each selected quality measure, the quality outcome must be reported for at least 50% of all eligible patients/encounters regardless of payer. (This threshold will increase to 60% in 2018 and 90% in 2019.)

The following table compares the reporting requirements for the MIPS Quality performance category with those for the now-expired PQRS program.

Comparison of MIPS Quality performance criteria with PQRS.

Program MIPS Quality PQRS
(registry-based reporting)
PQRS
(measures group reporting)
Number of quality measures that must be reported Exactly 6 At least 9 All measures included in the measures group
Additional measure restrictions At least one (1) measure must be an outcomes measure or, if no relevant outcomes measure is available, a high-priority measure Selected measures must span at least three of the six National Quality Strategy (NQS) domains None
Data completeness requirement For each measure: at least 50%* of eligible patients, and not less than 20 patients; at least one patient must meet the quality objective For each measure: at least 50% of eligible patients, and not less than 20 patients; at least one patient must meet the quality objective 20 patients
Payer restrictions None: Data must be submitted for all payers Only patients with Medicare as the primary payer At least 11 patients must have Medicare as the primary payer

* This threshold increases to 60% for 2018 and 90% for 2019 and beyond.

Quality Scoring: Basics

Ten (10) possible “category points” are available for each of the six reported measures, for a total possible category score of 60 category points. In 2017, this translates to a possible 60 MIPS CPS points.

For each measure, category points are awarded by comparing the performance rate with decile benchmarks that, in most cases, are pre-determined. For example, here are the 2017 decile benchmarks for Measure 178, which is a rheumatology-specific measure.

Decile breaks for Measure 178: Rheumatoid Arthritis (RA): Function and Status Assessment

Decile 3 4 5 6 7 8 9 10
Lower bound 27.99 45.96 64.18 74.47 81.37 87.83 92.35 99.72
Upper bound 45.95 64.17 74.46 81.36 87.82 92.34 99.71 100

In this example, a provider who reports a performance rate of 78% would fall in decile 6 (74.47-81.36%), and therefore he or she would receive between 6 and 7 category points for this measure. (Partial category points are awarded for performance rates that fall between decile breaks.)

Quality Scoring: Advanced Concepts

Some Quality measures, including some rheumatology measures, do not have decile benchmarks established in advance. In these cases, CMS will establish benchmarks from the data submitted for the performance year provided that at least 20 providers submit that measure with at least 20 patients/encounters each.

There are a few additional scoring rules:

  • Any provider who fails to report a measure required under this category will receive zero (0) category points for that measure.
  • For measures that cannot be scored, either because the data completeness requirement is not met or because no decile benchmarks can be set from the submitted data, a provider will automatically receive three (3) category points.
  • The first reported high priority measure is required to be reported. Thereafter, each additional outcome or patient experience measure receives two (2) bonus category points, and other additional high priority measures receive one (1) bonus category point, provided data completeness requirements are met.
  • Any measure submitted with “end-to-end” electronic reporting is eligible for one (1) bonus category point. End-to-end electronic reporting means the reporting process is fully automated and does not involve a manual abstraction or data entry step.

How to Report

In general, reporting Quality measures will require submission of clinical and claims data to CMS via a qualified registry, an entity specifically approved by CMS for this purpose. Some electronic health record (EHR) systems offer submission options for certain quality measures.

Measure Selection

The Quality Payment Program identifies a rheumatology-specific Specialty Measure Set, composed of 13 rheumatology-relevant quality measures. This is a good place to look for candidate measures to report. However, the Specialty Measure Set is not the same thing as a PQRS Measures Group: it is not necessary to report all the measures in the Specialty Measure Set, nor is it necessary for rheumatology providers to select only from these measures.

The following QPP measures are particularly relevant for rheumatology providers.

Rheumatology-related QPP measures for the Quality performance category.

# Measure Name
47 Advance Care Plan
109 Osteoarthritis (OA): Function and Pain Assessment
111 Pneumonia Vaccination Status for Older Adults
128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
130 Documentation of Current Medications in the Medical Record
131 Pain Assessment and Follow-Up
154 Falls: Risk Assessment
155 Falls: Plan of Care
176 Rheumatoid Arthritis (RA): Tuberculosis Screening
177 Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
178 Rheumatoid Arthritis (RA): Functional Status Assessment
179 Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
180 Rheumatoid Arthritis (RA): Glucocorticoid Management
226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
236 Controlling High Blood Pressure
238 Use of High-Risk Medications in the Elderly
317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
408 Opioid Therapy Follow-up Evaluation
412 Documentation of Signed Opioid Treatment Agreement
414 Evaluation or Interview for Risk of Opioid Misuse
431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

Not all measures are available through all submission options: the method of submission, for example the choice of qualified registry, may limit the measures that can be reported. Conversely, a registry that is approved by CMS as a Qualified Clinical Data Registry (QCDR) may have unique measures that can be submitted only through that registry. For example, some specialist societies also function as QCDRs and offer specialty-specific, non-QPP measures.