2023 Quality Performance Results:
Quality performance results are based on the Administrative Claims, CAHPS for MIPS Survey and MIPS CQM collection type.
| Measure # | Measure Name | Collection Type | Reported Performance Rate | Current Year Mean Performance Rate (SSP ACOs) | |
|---|---|---|---|---|---|
| Quality ID#: 001 | Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | MIPS CQM | 23.45 | 35.18 | |
| Quality ID#: 134 | Preventive Care and Screening: Screening for Depression and Follow-up Plan | MIPS CQM | 67.36 | 43.70 | |
| Quality ID#: 236 | Controlling High Blood Pressure | MIPS CQM | 81.16 | 69.63 | |
| Quality ID#: 321 | CAHPS for MIPS | CAHPS | 4.58 | 6.25 | |
| Measure # 479 | Hospital-Wide, 30-Day, All-Cause, Unplanned Readmission (HWR), Rate for MIPS Eligible Clinician Groups | Administrative Claims | 0.1615 | 0.1553 | |
| Measure # 484 | Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions | Administrative Claims | — | 35.39 | |
| CAHPS-1 | Getting Timely Care, Appointments, and Information | CAHPS for MIPS Survey | 82.38 | 83.68 | |
| CAHPS-2 | How Well Providers Communicate | CAHPS for MIPS Survey | 91.80 | 93.69 | |
| CAHPS-3 | Patient’s Rating of Provider | CAHPS for MIPS Survey | 88.43 | 92.14 | |
| CAHPS-4 | Access to Specialists | CAHPS for MIPS Survey | 77.90 | 75.97 | |
| CAHPS-5 | Health Promotion and Education | CAHPS for MIPS Survey | 60.92 | 63.93 | |
| CAHPS-6 | Shared Decision Making | CAHPS for MIPS Survey | 71.56 | 61.60 | |
| CAHPS-7 | Health Status and Functional Status | CAHPS for MIPS Survey | 52.01 | 74.12 | |
| CAHPS-8 | Care Coordination | CAHPS for MIPS Survey | 81.38 | 85.77 | |
| CAHPS-9 | Courteous and Helpful Office Staff | CAHPS for MIPS Survey | 88.45 | 92.31 | |
| CAHPS-11 | Stewardship of Patient Resources | CAHPS for MIPS Survey | 28.23 | 26.69 |
For previous years’ Financial and Quality Performance Results, please visit: Data.cms.gov