Quality Payment Program performance data for 2017 will be publicly available on Physician Compare website in late 2018 to help the Medicare beneficiaries and caregivers make informed decisions, and to encourage clinicians to deliver quality care. With that, MIPS score and its impact on reputation will begin to get very real. It must provide some solace to high performing providers who were underwhelmed by mere 2.02% in positive payment adjustment. To the chagrin of many, this data will serve as the MIPS report card for all providers participating in QPP (MIPS, APMs). So, it would be best to understand what data would be published on Physician Compare, in what format, and for whom.
Who will be included?
Providers with approved status in the Provider Enrollment, Chain, and Ownership System (PECOS) with a valid practice location and specialty who have submitted a Medicare fee-for-service claim, or are newly enrolled within last six months will have their data reported on Physician Compare.
PECOS, claim data, and board certifications serve as the source of information published on Physician Compare. So, ensure that your information is up-to-date in PECOS as it can take 2-4 months for changes in PECOS to be reflected on Physician Compare.
What will be published?
Data for certain measures under each performance category, the performance category scores, and the composite performance score (MIPS score) would be available for public reporting for clinicians and groups in late 2018. Additionally, aggregate MIPS information, including range of performance for all MIPS eligible clinicians within each performance category and the range of final scores for all MIPS eligible clinicians will also be published periodically on Physician Compare.
However, it’s important to note that only the data that meets the following criteria will be made public:
Meets the established public reporting requirements unless otherwise required by statute
Is statistically valid, reliable, and accurate
Is comparable across submission mechanisms or collection types (Claims, EHR, Registry, QCDR, CMS Web Interface)
Meets the minimum reliability threshold
Proven to resonate with patients and caregivers via user testing
Quality Performance Category
For the Quality category, the measure level performance would be displayed on Physician Compare along with the category level performance. Although all collection types will be tracked as they are all available for public reporting, only one collection type per measure will be made public for 2017 data. This approach is adopted in congruence with the public reporting standard that the data must be comparable. Furthermore, this approach ensures that the variations in score are due to variation in performance, and not due to the different benchmarks or the measure specifications for different collection types or submission methods.
Due to variety of the Quality measures, the performance is indicated in a variety of formats:
Measure Level Star Ratings: Only a subset of 2017 MIPS quality measures that meet the established public reporting standards and additional level of reliability testing, will be reported as measure-level star ratings in 2018. The Achievable Benchmark of Care (ABC™) methodology has been used to develop the benchmarks to indicate 1-5 stars for each measure.
Percent Performance Scores: QCDR measures (non-MIPS measures) will be reported as percent performance scores.
Top Box Scores: CAHPS for MIPS measures that meet the public reporting requirements will be reported as top box scores*, which is a method suggested for CAHPS by Agency for Healthcare Research and Quality (AHRQ), and proven to be well understood based on previous user testing.
*Top-Box refers to the most favorable points on the scale (e.g. most likely to recommend, most satisfied).
Promoting Interoperability Performance Category (formerly ACI)
The performance for Promoting Interoperability category would be reported in three ways:
An indicator for satisfactory and high PI performance when and where feasible
Attestations might be reported on clinician and group profile pages using check marks and plain language descriptions
The performance on PI measures would be reported if the measures meet the public reporting standards
In keeping with the overall public reporting policy, the PI measures newly introduced in 2017 will not be reported.
Improvement Activities Performance Category
The Improvement Activities performance category was introduced in 2017 for the very first time. Hence all activities are considered to be first year activities for 2017 and will not be publicly reported. IA will show up on Physician Compare in future years though.
Cost Performance Category
2017 data for the Cost category will not be reported as it was not used to calculate MIPS score, but it might be reported in future years.
Some APM participant information will also be available indicating if they participated in the Quality Payment Program and links to the APMs they participated in. CMS is still evaluating what performance related information to report publicly for the APM participants.
What will not be published?
Brand-new measures being collected for the first time will not be reported on Physician Compare in the subsequent year. For 2017, this is applicable to all the Improvement Activities, few Promoting Interoperability measures, and some Quality measures.
Additionally, voluntary data reported by clinicians who were not considered to be eligible clinicians for 2017, will not be posted on Physician Compare for 2018.
Furthermore, under the Quality category, the Non-proportional measures (continuous and ratio) and the outcome measures that are not risk-adjusted will not be publicly reported in 2018.
Hidden Truth: The Downloadable Database
Not many are aware that some performance information that meets the public reporting standards, but is not published on Physician Compare site, will still be available in the form of downloadable database. This information would potentially be used by physician ranking websites, insurance companies for determining the network of providers, and for physician recruitment. So, the impact of this data will spread far and wide, beyond the confines of Physician Compare site.
Stay Informed: Preview the Data
Fortunately, the 2017 performance data will be available for verification for a 30-day preview period in late Fall 2018 before being published on Physician Compare and made available as a downloadable database. CMS will be announcing details of which measures will be published shortly, and it will serve providers well to stay on top of it. Correct Enterprise Identity Management (EIDM) account and appropriate user role are required to access the Provider Quality Information Portal (PQIP), where you can preview performance data for all the measures, performance categories and MIPS score. If any providers have left or joined your practice since the end of 2017 performance period, also check the PECOS data to make sure all the information is up-to-date there.
The penalty avoidance approach by submitting minimum data might come back to bite now. Still, all is not lost. 2018 submissions are still a quarter away. Analyzing MIPS data for all performance categories will give an idea where you stand, what you can do to improve your MIPS score, and what is the best method to submit MIPS data. MyMipsScore can help with that.