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2023 Quality Performance Results:

Quality performance results are based on CMS Web Interface Measure Set. 

Measure # Measure Name Collection Type Rate ACO Mean
CAHPS-1 Get Timely Care, Appointments, and Information CAHPS for MIPS Survey 82.81 83.68
CAHPS-2 How Well Providers Communicate CAHPS for MIPS Survey 94.77 93.69
CAHPS-3 Patient's Rating of Provider CAHPS for MIPS Survey 93.80 92.14
CAHPS-4 Access to Specialists CAHPS for MIPS Survey 76.97 75.97
CAHPS-5 Health Promotion and Education CAHPS for MIPS Survey 66.15 63.93
CAHPS-6 Shared Decision Making CAHPS for MIPS Survey 67.89 61.60
CAHPS-7 Health Status and Functional Status CAHPS for MIPS Survey 72.88 74.12
CAHPS-8 Care Coordination CAHPS for MIPS Survey 86.91 85.77
CAHPS-9 Courteous and Helpful Office Staff CAHPS for MIPS Survey 90.94 92.31
CAHPS-11 Stewardship of Patient Resources CAHPS for MIPS Survey 23.01 26.69
Measure #: 001 Diabetes: Hemoglobin A1c (HbA1c) Poor Control CMS Web Interface 9.68 9.84
Measure #: 134 Preventative Care and Screening: Screening for Depression and Follow-up Plan CMS Web Interface 86.53 80.97
Measure #: 236 Controlling High Blood Pressure CMS Web Interface 75.40 77.80
Measure #: 318 Falls: Screening for Future Fall Risk CMS Web Interface 100.00 89.42
Measure #: 110 Preventative Care and Screening: Influenza Immunization CMS Web Interface 64.04 70.76
Measure #: 226 Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention CMS Web Interface 79.17 79.29
Measure #: 113 Colorectal Cancer Screening CMS Web Interface 82.66 77.14
Measure #: 112 Breast Cancer Screening CMS Web Interface 82.66 80.36
Measure #: 438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease CMS Web Interface 90.99 87.05
Measure #: 370 Depression Remission at Twelve Months CMS Web Interface 13.48 16.58
Measure #: 321 CAHPS for MIPS CMS Web Interface 6.99 6.25
Measure #: 479 Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups Administrative Claims 0.1639 0.1553
Measure #: 484 Clinician and Clinician Group
Risk-standarized Hospital Admission Rates for Patients with Multiple Chronic Conditions
Administrative Claims 34.00 35.39

For Previous Years’ Financial and Quality Performance Results, please visit data.cms.gov.

Fraud and Abuse Waivers

A2299 Waiver disclosures, updated November 2024


 
 
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