The Merit-based Incentive Payment System (MIPS) adjusts Medicare payments for clinicians based on performance in four categories, established under the Medicare Access and CHIP Reauthorization Act (MACRA). The Quality category is the largest component of a clinician’s total MIPS score, typically accounting for 30% of the final result. This category measures the quality of care provided to patients, focusing on evidence-based practices and outcomes. Understanding the structure and scoring of these Quality Measures is fundamental for providers participating in this value-based reimbursement system.
The Anatomy of a Quality Measure
Every MIPS Quality Measure is structured like a fraction, containing specific components that define the eligible patient population and the required action. The denominator identifies the specific group of patients or care instances eligible for the measure, often narrowed by factors like age, diagnosis, or procedure. For example, a measure might target all patients aged 18 to 75 with a diagnosis of diabetes.
The numerator represents the successful action or desired outcome within that eligible patient pool. Using the diabetes example, the numerator might be the number of those patients who received a hemoglobin A1c test during the performance period. Dividing the numerator by the denominator calculates a performance rate, reflecting the percentage of eligible patients who received the desired care.
The measure specifications also include exclusions and exceptions, allowing certain patients to be removed from the denominator. Exclusions apply to patients who meet the denominator criteria but have a documented reason why the measure is not applicable, such as a medical contraindication or patient refusal. This ensures the calculated performance rate accurately reflects the quality of care provided to the appropriate target population.
Reporting Methods and Requirements
To participate in the Quality category, clinicians must adhere to specific reporting requirements regarding the number of measures and the duration of data collection. Clinicians must report data on at least six Quality Measures for the entire 12-month performance period (January 1st through December 31st). This selection must include at least one Outcome measure or, if unavailable, one High Priority measure.
The data used to calculate these measures can be submitted through one of five collection types, offering flexibility based on a practice’s technology. These methods include MIPS Clinical Quality Measures (MIPS CQMs) submitted via a registry or EHR, and Electronic Clinical Quality Measures (eCQMs) reported directly from Certified EHR Technology. Other options include measures calculated from Medicare Part B Claims data (only available to small practices) and Qualified Clinical Data Registry (QCDR) measures.
A requirement for any submission method is data completeness: data must be reported for a minimum of 75% of the eligible denominator cases for each measure. If this threshold is not met, the measure will receive a score of zero points. Clinicians can combine measures from different collection types to satisfy the requirement of reporting six measures.
How Quality Performance is Scored
A clinician’s raw performance rate on a measure is converted into MIPS points through a process called benchmarking, which compares their performance against national data. This comparison uses historical data submitted by MIPS participants to establish a performance range for each measure. These established ranges are divided into ten segments, known as deciles.
The number of points a measure earns is determined by the decile in which the clinician’s performance rate falls, with scores ranging from three to ten points. For instance, performance falling into the eighth decile earns between 8.0 and 8.9 points. A measure must also meet a minimum case volume, typically 20 eligible patient cases, to be scored against the benchmark.
If a measure is reported with insufficient case volume or lacks a benchmark, it receives a floor score, often capped at three points. Practices may earn bonus points for reporting high-priority measures beyond the minimum requirements or for submitting data using end-to-end electronic reporting from their EHR system. The top six scoring measures are used to calculate the final Quality category score.
Financial Impact of Quality Measures
The calculated Quality category score contributes to the clinician’s overall MIPS Final Score, which determines the financial adjustment to Medicare payments. The Quality category typically accounts for 30% of the total MIPS score, though this percentage can increase if a clinician is exempt from other categories like Promoting Interoperability or Cost.
The combined MIPS Final Score (derived from the Quality, Cost, Improvement Activities, and Promoting Interoperability categories) is compared against a performance threshold set by the Centers for Medicare & Medicaid Services (CMS). A score below this threshold results in a negative payment adjustment, while a score above the threshold earns a positive adjustment. These payment adjustments are applied two years after the performance year, directly impacting Medicare reimbursement rates.