Measure # |
Measure Name |
Collection Type |
Rate |
ACO Mean |
CAHPS-1 |
Get Timely Care, Appointments, and Information |
CAHPS for MIPS Survey |
83.73 |
83.96 |
CAHPS-2 |
How Well Providers Communicate |
CAHPS for MIPS Survey |
92.48 |
93.47 |
CAHPS-3 |
Patient's Rating of Provider |
CAHPS for MIPS Survey |
90.73 |
92.06 |
CAHPS-4 |
Access to Specialists |
CAHPS for MIPS Survey |
71.32 |
77.00 |
CAHPS-5 |
Health Promotion and Education |
CAHPS for MIPS Survey |
61.72 |
62.68 |
CAHPS-6 |
Shared Decision Making |
CAHPS for MIPS Survey |
62.44 |
60.97 |
CAHPS-7 |
Health Status and Functional Status |
CAHPS for MIPS Survey |
71.75 |
73.06 |
CAHPS-8 |
Care Coordination |
CAHPS for MIPS Survey |
84.14 |
85.46 |
CAHPS-9 |
Courteous and Helpful Office Staff |
CAHPS for MIPS Survey |
91.07 |
91.97 |
CAHPS-11 |
Stewardship of Patient Resources |
CAHPS for MIPS Survey |
25.82 |
25.62 |
001 |
Diabetes: Hemoglobin A1c (HbA1c) Poor Control |
CMS Web Interface |
8.78 |
10.71 |
134 |
Preventative Care and Screening: Screening for Depression and Follow-up Plan |
CMS Web Interface |
88.24 |
76.97 |
236 |
Controlling High Blood Pressure |
CMS Web Interface |
70.56 |
76.16 |
318 |
Falls: Screening for Future Fall Risk |
CMS Web Interface |
100.00 |
87.83 |
110 |
Preventative Care and Screening: Influenza Immunization |
CMS Web Interface |
82.11 |
77.34 |
226 |
Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention |
CMS Web Interface |
94.44 |
79.27 |
113 |
Colorectal Cancer Screening |
CMS Web Interface |
73.39 |
75.32 |
112 |
Breast Cancer Screening |
CMS Web Interface |
77.42 |
78.07 |
438 |
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease |
CMS Web Interface |
88.51 |
86.37 |
370 |
Depression Remission at Twelve Months |
CMS Web Interface |
10.94 |
16.03 |
479 |
Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups |
Administrative Claims |
0.1674 |
0.1510 |
MCC1 |
All-Cause Unplanned Admissions for Patients with
Multiple Chronic Conditions for ACOs (MCC) |
Administrative Claims |
30.88 |
30.97 |