Quality Performance 2021

Assuming that a clinician or group is scored under all four performance categories, the Quality performance category will be worth 40 percent of the Merit-based Incentive Payment System (MIPS) final score in 2021; the category weight was increased 5 percentage points from 2020 to 2021. 

Quality Reporting Requirements

• As in previous years, surgeons are expected to report on a minimum of six measures, including one outcome measure (a high-priority measure may be substituted if an outcome measure is not available) for the duration of the performance year (12 months).
• To receive a performance score on a measure, clinicians or groups must report quality data for 70 percent of all patients to which each measure is applicable, regardless of payor, over the course of the 2021 calendar year.
• To achieve full credit for this category, you will need to earn 60 Quality measure points. Each Quality measure is worth a maximum of 10 points, but there are many situations where the points available for reporting a measure are capped below 10 points, making it increasingly difficult to achieve 60 points for this category.

Ways to Report Quality Data

The Centers for Medicare and Medicaid Services (CMS) offers numerous clinical quality measures (CQMs) for MIPS reporting, and has organized some of these measures into specialty measure sets. For example, general surgeons can utilize the General Surgery specialty measure set to determine which MIPS measures might fit best with the care they provide. The 2021 MIPS measures are available through the QPP Resource Library. 
Depending on the measures selected, surgeons can choose from the below Quality data submission mechanisms.

• Claims (Claims reporting is only available to surgeons in small practices. Those who report through claims only have to report on Medicare patients)
• Qualified Clinical Data Registry (QCDR)
• Qualified Registry 
• Electronic Health Record (EHR)
• CMS Web Interface (groups of 25 or more)
• CMS-approved survey vendor for Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS (must be reported in conjunction with another data submission mechanism)

How Are Quality Measures Scored? 

Surgeons may receive between 3 and up to 10 points for quality measures submitted during the 2021 performance period when they report at least 20 cases, meet the 70 percent data completeness threshold, and when the measure has a benchmark.

Quality measures are scored as follows:

• 3 to 10 points—A surgeon will receive 3 to 10 points based on performance compared to a historical or performance year benchmark as long as the measure meets the data completeness criteria, has a benchmark, and has a sufficient number of cases (>20 cases for most measures)
• 3 points—A clinician will receive 3 points if they meet the data completeness criteria, but either (1) the measure doesn't have a benchmark and/or (2) they do not meet the case minimum.
• Measures that do not meet the data completeness criteria, regardless of case minimum or benchmark, will earn 0 points.
• Clinicians in small practices will still receive 3 points on a measure, even if it does not meet the data completeness criteria.

Additional Factors That Can Affect Quality Measure Scoring

• Many measures that are most relevant to surgeons are now considered "topped-out." This makes it extremely hard to earn 60 points in Quality, because many of these measures are subject to scoring caps where the highest achievable score for the measure is 7 points.
• MIPS measures can also be subject to scoring caps if they do not have a benchmark for all 10 deciles. This happens when about 10 percent to 60 percent or more of clinicians performed at the maximum achievable performance rate. In these situations, performance scores lower than 100 percent are capped at the specified level. In the example below, if a clinician's performance is anything less than 100 percent, he/she can only earn up to 5 points on the measure:

Bonus Points

• Two bonus points can be earned for reporting additional outcome measures and one bonus point can be earned for reporting additional high-priority measures, beyond what is required for full Quality reporting. CMS will only provide performance scores for a physician's top six performing measures, but any outcome and high priority measures reported beyond those six are eligible for bonus points and should be considered a way to boost your Quality category score.
• Small practices will receive a 6-point bonus added to their Quality performance score when they submit data on at least 1 quality measure.
• Surgeons can also receive up to 10 bonus points in Quality for demonstrating improvement in the category, overall, from year to year.

How to Achieve the 2021 MIPS Performance Threshold and Avoid a Payment Penalty

In the 2021 MIPS performance year, surgeons must earn 60 MIPS overall points to meet the performance threshold and avoid a payment penalty in 2023. In the past, you could still meet the performance threshold without meeting the reporting requirements for all four MIPS performance categories, but this is no longer the case due to a higher performance threshold and changes to the performance category weights. The ACS recommends that you plan to fully report in the Promoting Interoperability, Quality, and Improvement Activities categories (Cost is calculated by CMS) to have the best chance of avoiding a negative payment adjustment for the 2023 payment year. 

CMS also offers many resources on their Quality Payment Program website, and is a great resource for learning about and selecting Quality measures, Promoting Interoperability measures, and Improvement Activities for reporting in 2021.

Hospital Value-Based Purchasing Program

CMS will automatically use the Hospital Value-Based Purchasing (VBP) Program score of a facility-based clinician or group in lieu of a Merit-based Incentive Payment System (MIPS) score if the VBP score is higher than the clinician's combined Quality and Cost score under MIPS. CMS calculates the facility-based score automatically using the facility's Total Performance Score determined through the Hospital VBP Program. Surgeons are not required to opt-in or take any specific action to be eligible, but should use the QPP Participation Look-Up Tool to determine whether they meet the definition of "facility-based" and to which facility they are attributed. Surgeons who are eligible for facility-based scoring can still report MIPS Quality measures, but CMS will automatically use the facility's score if it is higher than their combined Quality and Cost MIPS scores. CMS will provide details about how surgeons were scored for MIPS through the 2020 MIPS feedback reports, which are expected to be released in July 2021.

Facility-Based Criteria

Individual clinicians are considered facility-based if they meet all the following criteria:

• Billed at least 75 percent of covered professional services in a hospital setting.
• Billed at least one service in an inpatient hospital or emergency room and can be attributed to a facility with a Hospital VBP score.
• If a clinician works at multiple facilities, CMS will attribute the clinician to the hospital where they provided services to the greatest number of Medicare beneficiaries during the determination window using the same TIN/NPI combination.
• A group practice would be considered facility-based if 75 percent or more of the MIPS-eligible clinicians in a group are deemed facility-based. CMS will attribute the group to the hospital where the plurality of clinicians in the group were attributed as individuals.

The 2021 Performance Year

For the 2021 MIPS performance year, CMS will rely on FY 2022 Hospital VBP Program scores for facility-based scoring. FY 2022 hospital scores will not be released to the public until early in 2022, but clinicians should be able to view FY 2021 hospital scores here in early 2021 to get a general sense of where a facility falls compared to others.  Some surgeons are tied to high-performing facilities and could rely on the facility score to achieve a high MIPS score, but that may not be the case for all, making it important to understand how your facility has historically scored and compared with other facilities in the Hospital VBP Program.

Please note: Hospital-based status is different than facility-based status. Hospital-based status has different eligibility criteria and is used to determine if a clinician or group is exempt from the Promoting Interoperability (PI) category. As mentioned, facility-based status is used to determine whether the clinician or group is eligible for facility-based scoring. Although the statuses are different, it is possible to fall into both categories. Surgeons who are considered both hospital-based and facility-based will receive an automatic reweighting of PI to Quality and are also eligible to have their facility's Hospital VBP Program score applied to Quality and Cost.