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2022 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 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

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

Fraud and Abuse Waivers

A2299 Waiver disclosures, updated September 2023


 
 
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