Mastering MIPS Quality Measures: The Intricacies of Point Potential, Performance Management, and Data Completeness
Quality is KING when it comes to the Merit-based Incentive Payment System (MIPS) and it’s common to see discussions on choosing the right quality measures to maximize performance. (Goodness, we wrote a bunch of those and we talk about this all the time.) However, understanding the more nuanced aspects such as decile point potential, continuous performance surveillance, and effective management strategies, along with the critical 70% data completeness requirement is equally important. Here, we delve into these lesser-discussed, yet pivotal components of MIPS quality measures.
Decile Point Potential: A Stepping Stone to High Performance
In MIPS, each measure is associated with a point potential based on the decile performance of all clinicians reporting on that measure. This point potential offers a strategic way to earn more points, not just by performing well, but by understanding where your performance stands relative to your peers.
Your performance score for a measure will depend on which decile you fall into. The higher the decile, the more points you'll earn, with the maximum being 10 points. However, the decile thresholds vary from measure to measure and year to year, making it essential to keep track of changes in your relative performance.
Understand that the benchmarks and deciles are based on historical data. As healthcare practices improve, what was once a top decile performance may no longer be so in the following year. Therefore, clinicians need to constantly monitor their performance to ensure they maintain or improve their decile position.
Performance Surveillance and Management Strategies
Surveillance in MIPS performance isn't about checking a box—it's about embracing a culture of continuous performance improvement. A strong performance management strategy helps practices identify areas of strength, uncover potential weaknesses, and take corrective actions when necessary. Some key aspects to consider include:
Continual Performance Measurement: You should constantly measure your performance on MIPS quality measures, not just at the end of the reporting period. This helps identify issues early and provides opportunities for corrective action.
Data-Driven Decision Making: Use the data from your performance measurement to inform your decisions. This can range from identifying areas where your performance is weak and needs improvement, to understanding the potential impact of changing a process or procedure on your MIPS score.
Staff Training: Make sure that everyone on your team understands MIPS and the importance of quality measures. Regular training sessions can ensure that everyone is on the same page and working towards the same goals.
Patient Engagement: Engage patients in their care. When patients understand why certain processes or procedures are important, they are more likely to adhere to treatment plans and follow through with recommendations, ultimately improving your performance on quality measures.
Meeting the 70% Data Completeness Criteria
To be eligible for scoring, each MIPS quality measure must meet the 70% data completeness requirement. This means that clinicians need to report data on at least 70% of all eligible instances (patient encounters or procedures) where the measure could have been applied, regardless of payer.
It’s vital to have a robust data collection and reporting process in place. Failure to meet the data completeness criterion may lead to a lower score for that measure or even risk an eligibility penalty.
While selecting the right measures is essential, understanding the intricacies of MIPS extends beyond that. Grasping the concept of decile point potential and the importance of constant performance surveillance can help you remain competitive. Lastly, always remember that you're required to meet the 70% data completeness criteria to avoid penalties. Incorporating these elements into your MIPS strategy will put you on the path to success and contribute to improved patient outcomes.
Need help selecting the right Quality measures or having an expert do MIPS for your office? Chirpy Bird can help. Contact us by phone at 888-647-7247 or email us at hello@chirpybirdinc.com today!
