CMS Quality Public Reporting
CMS Quality Public Reporting Quick FAQs
The 2010 Patient Protection Affordable Care Act (PPACA) required that the Centers for Medicare & Medicaid Services (CMS) make information on quality and patient experience measures publicly available. Therefore, the Physician Compare website was created as a source of information for Medicare beneficiaries, clinicians and other professionals who are stakeholders in physician quality.
In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) established the Quality Payment Program (QPP), where providers earn performance-based payment adjustments through the Merit-based Incentive Payment System (MIPS). The MIPS program began on January 1, 2017 and consolidates the Physician Quality Reports System (PQRS) data that was publicly reported. Consumers will continue to be able to view quality data for Medicare providers that participate in MIPS or in an Advanced Alternative Payment Model (APM).
Physician Compare provides information to help Medicare beneficiaries find providers and learn about group practice affiliation. It includes indicators that identify providers who participate in quality reporting, use electronic health record technology, and participate in health initiatives like Million Hearts.
What type of provider data does CMS publicly report?
CMS first published quality data on the Physician Compare site in February 2014 on a subset of 2012 Physician Quality Reporting System (PQRS) measures, which consisted of Group Practice Reporting Option (GPRO) measures for Diabetes Mellitus and Coronary Artery Disease. Sixty six group practices and 141 Accountable Care Organizations successfully reported using the GPRO web interface. In late 2014, CMS publicly reported a second subset of data on Physician Compare, reflecting data collected in 2013. Since then, CMS has continued to expand the reporting of quality information every year through its rulemaking process.
To date, CMS has not announced the level of detail that will be reported but will continue to indicate that clinicians participate in MIPS, use of EHRs and Million Hearts.
In the future, CMS plans to publicly report APM participation in 2018 as technically feasible. There will be an indicator that the individual clinician or group participated in an APM, and a link will be provided to the APM profile page for selected Advanced APMs and Shared Shavings Program Track 1 Accountable Care Organizations (ACOs).
CRNAs should be aware that first-use MIPS program measures from the Quality, Improvement Activities and Promoting Interoperability categories will not be publicly reported. Additionally, all non-proportional measures (continuous or ratio) and outcomes measures that are not risk-adjusted are not reported publicly.
What type of provider data does CMS privately report and make accessible to Eligible Clinicians?
MIPS Performance Measure data is generated from Qualified Registries (QR), Qualified Clinical Data Registries (QCDRs), EHR systems or files submitted to the CMS Web Interface. Beginning with the 2017 performance year, MIPS performance measure data will be published for individual clinicians and groups as the Performance Feedback Report. The reports consist of performance category scores and a final score. The performance measures are grouped into four categories: Quality, Promoting Interoperability (formerly known as Advancing Care Information), and Improvement Activities. Additional information about the Feedback Report can be found below.
The Performance Feedback Report based on the MIPS performance categories, will be released in late 2018, and will be accessible using the provider or group’s Enterprise Identity Management (EIDM) account number on Quality Payment Program . The Value Modifier previously found in the Quality and Resource Use Reports (QRUR) and PQRS Feedback reports will not be available for viewing or download after December 31, 2018. Providers can access their PQRS data using their EIDM until that time.
In general, what information is publicly available on the Physician Compare consumer website about individual providers and group practices?
Physician Compare only publishes information on individual Eligible Clinicians (ECs) and group practices who satisfactorily report under the Merit-based Incentive Payment System (MIPS).
Select Year 1 MIPS Quality Reporting data (CY2017) will be published for individual Eligible Clinicians (EC) and groups in late 2018. An individual provider or group’s Physician Compare profile will contain an indicator (i.e., a green checkmark) that will denote participation in the Quality Payment Program (i.e. ability to satisfactorily report).
If the provider or group participated in an Alternative Payment Model (APM) such as the Shared Savings Program Track 1 Accountable Care Organization (ACO), a link to that information will be provided on the website.
In addition to profile information, Physician Compare currently includes quality of care performance scores for group practices designated as Accountable Care Organizations (ACOs), which can be found on the MIPS Performance Feedback Fact Sheet. It is possible that APM performance information will be posted as well.
The Value Modifier and PQRS Feedback reports that are currently available through CMS.gov will not be available for viewing or download after December 31, 2018. Providers can access their PQRS data using their EIDM until that time.
In addition, public use downloadable files for the 2016 Physician Compare Database are still available on the Physician Compare website until December 31, 2018. This will include a subset of utilization data, which is a requirement under MACRA.
How does CMS decide what to publicly report on Physician Compare?
All measures available for public reporting on Physician Compare are decided via rule-making; however, not all measures available are publicly reported on the Physician Compare website. CMS decides which measures to publicly report based on their public reporting standards of reliability, validity, accuracy, and consumer relevance.
The CMS infographic below further explains how they select measures for public reporting on Physician Compare: (Click on thumbnail to enlarge)
What specific MIPS data will be publicly reported on the Physician Compare consumer website in 2018 and beyond?
Select Quality Payment Program Data for CY2017 in the following categories:
Quality Performance Category:
- Information about select quality measures and the total Quality performance category score. A subset of 2017 MIPS measures will be publicly reported as star ratings on the profile pages for groups practices.
- Select Qualified Clinical Data Registry (QCDR) measures will be publicly reported on individual clinician and group profile pages as percent performance scores.
- 2017 CAHPS for MIPS data - Information about group-reported measures from Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys are also included on the profile pages for physician groups. CAHPS for MIPS summary survey scores will be reported on group profile pages as top-box scores, which represent the percentage of patients who reported the most positive responses.
Promoting Interoperability (formerly Advancing Care Information) Performance Category:
Information will be reported in one of three ways:
- Attestations of Promoting Interoperability using checkmarks and plain-language descriptions
- As measures that meet public reporting standards
Cost and Improvement Activity Performance Category data will not be publicly reported given that they are new measures for CY2017.
Alternative Payment Models:
- CMS plans to publicly report APM participation in 2018 as technically feasible. There will be an indicator that the individual clinician or group participated in an APM, and a link will be provided to the APM profile page for selected Advanced APMs and Shared Shavings Program Track 1 Accountable Care Organizations (ACOs).
- Groups that participated in Next Generation or Medicare Shared Savings Program ACOs will also have indicators on their profile pages.
CMS is also targeting to publicly report an item-level benchmark using the Achievable Benchmark of Care or “ABC™” methodology. The earliest the Physician Compare benchmark was publicly reported was in late 2017, where it served as the basis of a ratings system. According to CMS, this benchmark will allow consumers to evaluate the information on Physician Compare publishes by providing context for performance scores and a point of comparison between groups as well as individuals. The benchmark currently applies to PQRS data and will transition to MIPS quality data.
For more information and a step-by-step demonstration on how the benchmark will be applied to a measure, view the Public Reporting Sessions Reference Document from the CMS website.
Will there be additional information publicly reported on the Physician Compare website?
Yes. Downloadable databases will be available for clinicians, healthcare administrative professionals, and researchers. In addition to the information provided on the Physician Compare consumer website, the downloadable database will include performance category scores for Improvement Activities and Promoting Interoperability (Advancing Care Information).
CMS plans to publicly report aggregate MIPS data periodically in downloadable databases.