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From The Editor: My Quality Measure To-Do List

As we ring in 2018, I’ve just reviewed my quality measure performance and I’m making my final choices regarding which measures I will report. The vast majority of medical practitioners became subject to the Merit-Based Incentive Payment System (MIPS) on Jan. 1, 2017. Most practitioners are just trying to avoid a 4% penalty by submitting one quality measure or improvement activity. I’m trying to achieve the maximum bonus money, which can be as much as 22% of your Medicare Part B payments. I’m trying to achieve a total score of 70 points or greater in order to access the “exceptional performance” bonus. A practitioner is much more likely to maximize points by submitting data through a qualified clinical data registry (QCDR). QCDR participation optimizes performance in all three aspects of MIPS that contribute to the 2017 composite score. The “quality” category contributes 60% of the total score in 2017, “advancing care information” — which is really Meaningful Use of the electronic health record (EHR) under a different name — contributes 25%, and “clinical practice improvement activities” (CPIAs) contribute 15% of the score. I am going to offer some tips for selecting your quality measures, in case you are evaluating your options. Remember that QCDRs are unique because they are allowed to develop quality measures that providers can report for MIPS credit, even though the measures may not be recognized for reporting at the national level. The U.S. Wound Registry (USWR) has 14 wound care and hyperbaric measures available for MIPS reporting, several of which are outcome measures. The “quality” score has three components: base points (maximum 60), bonus points (maximum 6), and certified EHR technology bonus points (CEHRT; maximum 6). Practitioners must submit six quality measures, each of which is worth a maximum of 10 points, so each quality measure is 10% of your total quality score in 2017. 

The way that your quality measure score translates to points is through the decile system. You can’t tell exactly where you are in terms of decile performance based on your raw score because the points are allocated in relation to everyone else’s performance. By way of example, I have decided that I will report documentation of medications — Physician Quality Reporting System (PQRS) 130 — because my score is 100%, so I am in the 10th decile. Because clinicians are incentivized to report their highest scoring measures, most of the doctors who report that measure do so because they scored 100%. In fact, so many doctors in the U.S. score 100% on that measure that you will drop to the 7th or 8th decile if you miss documenting medications on even one patient’s chart. That’s true for most (if not all) MIPS measures, particularly the very general ones, which are often chosen by healthcare organizations. Your performance has to be perfect or your decile ranking will be poor, and there goes your bonus money. 

You have to report at least one outcome measure through a QCDR; the Centers for Medicare & Medicaid Services (CMS) requires that the outcome measure be risk-stratified. Risk stratification is a tool used to level the playing field so that clinicians caring for the sickest patients do not appear to have worse outcomes than their peers. The USWR developed a risk-stratification system for wound healing known as the Wound Healing Index (WHI), which predicts the mathematical likelihood that a wound such as a diabetic foot ulcer (DFU) or venous leg ulcer will heal. This allows clinicians to move away from the disingenuous practice of claiming near-perfect wound healing rates by ignoring all the wounds that don’t heal or calling them “palliative” —  a practice that CMS does not allow.1 I am going to report DFU healing. My aggregate score is 44%, which puts me in decile 8.3. (Later I will tell you about my healing rate in various categories of severity.) 

I need to report four more measures. I won’t go through the entire process, but I’d like to point out something interesting: I could report PQRS 131 (pain assessment and follow up). My raw score is 97.1%, which seems good, but that’s a measure in which, because I do not have a perfect score of 100%, my decile ranking is only 7.7. On the other hand, there’s another USWR outcome measure — venous ulcer healing (stratified by the WHI) — where my raw score is only 43.5%. Actually, that’s not a bad score for venous ulcer healing, so my decile ranking is 7.2. On the face of it, you would say that I should still pick PQRS 131 since my decile ranking is 7.7 on that measure, which is better. However, clinicians receive 2 bonus points for each additional outcome measure reported. So, I am going to report venous ulcer healing as my second outcome measure, even though the decile ranking is slightly lower than one of the other MIPS measure choices, because it’s actually worth 2 additional bonus points. I should probably add that the reason the USWR’s measures are worth these extra points is that this is the third year they have been in use, so benchmark rates have been set for them (otherwise they would only be worth 3 points in total). If you are using QCDR measures, make sure you know whether they have been benchmarked. Unbenchmarked measures are only worth 3 points. I am also going to pick up all six of the CEHRT bonus points, because my EHR is transmitting all the quality data directly to the USWR without the need for any manual data entry. I am using a tool inside my EHR known as the “measure optimizer” that allows me to add or subtract quality measures from my basket based on my measure performance, which the EHR has already calculated.  The USWR will also review my final choices and make some suggestions if I have failed to recognize a way that I could better optimize my score, such as if I had not known the advantage of reporting the second outcome measure. Tips for optimizing your 2017 quality score include:

  • Report “end to end” electronically out of your EHR.
  • Report some QCDR quality measures, and not just the standard, national measures (so that your performance does not have to be perfect, which is typical for national measures).
  • Have more than one risk-stratified outcome measure (which, for wound care, is only available through the USWR)
  • Use QCDR measures that have been benchmarked, which means that they are in their third year of reporting and have a benchmark rate that you can beat!

Through the USWR, my CPIAs are tied to the quality measures I am reporting, so I am completing them as I work on my quality measures, evaluating where I stand in relation to the rest of the clinicians reporting those measures, and looking for opportunities to improve on any gaps in practice. I’ll have MIPS completed by the end of the day today (late in December), including the time it took to write this editorial. I hope next year you can take advantage of the USWR measures that will leverage “FHIR” (Fast Healthcare Interoperability Resources), the standard for healthcare information exchange. USWR quality measures will be able to integrate seamlessly with your hospital EHR as apps, thanks to the EHR interoperability initiative. We at Today’s Wound Clinic will keep working to make your 2018 a happy and prosperous one by providing you with the information you need to succeed. Best wishes in 2018!


1. Fife CE. Why Publicly Reported “Wound Healing” Rates are Pure Fiction … and How Truthful Reporting of Healing Rates Could Save the Field of Wound Care. 2017. Accessed online:

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