On June 11, 2021,MIPS CMS sent out an email with the most recent version of the 2021 quality benchmarks. The purpose of this blog post is to provide an overview of quality standards, the impact of recent modifications, and some ideas on how to maximize your quality reporting in 2021 despite the changes. In addition, we will discuss these improvements as well as how your Quality Improvement process for 2021 will be affected by them.
Explaining Quality Standards and Measures
Your performance score in the MIPS Quality 2022 Category is determined based on how well you perform in comparison to the benchmarks. The performance from the two years prior to the reporting period is taken by CMS and then divided into deciles based on that performance. Your score for the measure will be based on the decile that most closely corresponds to your performance during the reporting year. For the Pneumococcal Vaccination Status for Older Adults metric, for instance, let’s assume that you will attain a performance level of 84 percent in the year 2022. The chart that may be found below is an example of the Quality Benchmarks that CMS has established for this measure (CMS 111).
When reporting using the Direct EHR (eCQM) Collection Type in 2022, a performance of 85 percent will get you at least 9 points (with a range of 9-9.9) The use of benchmarks enables more informed decisions to be made regarding the quality of the reporting. The benchmarks are able to assist in determining the most advantageous approach to report, in addition to assisting in the identification of your reporting score.
To reiterate, if you look at the chart that was just presented, your provider (or providers) will receive 9 points if they submit the measure as an eCQM. However, if they submitted the measure through a registry (the collection type for MIPS CQM), you would only gain 8 points for that same performance rate, which means that reporting the measure directly through your EHR is the more advantageous alternative in this scenario. As a result, it is essential to have an understanding of the standards and to make use of them as a tool in order to facilitate the maximization of your quality score.
The Effects of Recent Alterations
In their newsletter dated 11 June, CMS explained that these revisions were made available in order to rectify an error that occurred with the decile margins. In essence, the margins were off by one decile across the board in their original publication of the 2021 benchmarks. This was the case for all of the measurements. As a result of the change, your performance rate for each measure will be one decile lower than you anticipated if you were measuring your quality performance by using the original benchmark file. This is the case if you were tracking your quality performance. CMS explained that they wanted to be open and honest about the discrepancy and take responsibility for the error that was made in the initial filing.
It is essential to emphasize the fact that there are a number of quality measurements that do not have norms for the year 2021. Any metric that does not have a predetermined standard for the year 2021 will be awarded a maximum score of three points (plus any applicable bonus points).
Improving the Quality of Your Reports for the Year 2021
As you move into the second half of the reporting year, it is imperative that you have a solid understanding of what you are capable of doing and the resources at your disposal in order to guarantee that you get the highest possible quality performance score. Consider the following advice in this regard:
You can review the QPP Resource Library’s benchmarks by downloading them and reading them.
As was mentioned earlier, keeping track of both your performance and your project score throughout the course of the year will assist you in making educated judgments on the metrics that you choose to report.
Be aware that you can report on a variety of different types of collections.
You are able to report some measures from the registry as well as some metrics from your EHR for patients who are also participating in registries to report quality. CMS will give you a grade based on the six measures in which you performed the best out of numerous submission options (such as Direct EHR, Registry, or Claims) (for small practices only).
Gain an understanding of the benefits of direct EHR reporting.
You are eligible for electronic end-to-end reporting bonus points when you report via Direct EHR or when you report to the registry directly from your EHR. In most circumstances, this is the case (1 point per measure submitted electronically).
Consult with Regulatory Experts for Assistance
Check with the provider of your electronic health record system (EHR) to see if they have a team of specialists that can assist you in frequently reviewing your performance and putting you on the best path to increased performance by 2021.
