Skip to content
1-866-359-4458 Log In
Get Started

Analyzing QCDRs vs. Qualified Registries, CAHPS for MVPs, Improving MIPS Scores, & more | Ask Dr. Mingle

In this week’s episode of Ask Dr. Mingle, Dr. Dan Mingle answers listener questions about Qualified Clinical Data Registries (QCDRs) vs. Qualified Registries (QRs), MIPS Value Pathways (MVP) availability and QCDRs, how to improve MIPS scores, and more.

Before we start, here is some context for our first four questions in this episode: Becky represents an emergency medicine group and presents a series of questions about MIPS Value Pathways (MVPs).

Question One: Qualified Clinical Data Registries (QCDRs) vs. Qualified Registries (QRs) for MVPs

Becky’s first question: “We are evaluating Qualified Clinical Data Registries vs. Qualified Registries. QCDRs vs QRs. Will QCDRs continue with MVPs as well as QRs?”

My answer, with one disclaimer, is yes.

The disclaimer is that making confident predictions of future Medicare actions or policies is hazardous.

But with everything I see, you can expect both Qualified Clinical Data Registries and Qualified Registries to continue to serve MVPs.

In fact, you’ll find all existing quality submission mechanisms represented in the twelve MVPs available for 2023.

Medicare has aggressive plans to continue to build out MVP measures. To me, that means they will have to continue to aggressively seek out and offer measure choices from all available sources.

MVP users must choose four quality measures available in their chosen MVP. MVPs average ten available measures, each with a range of seven at the least, to fourteen, at the most.

  • MIPS CQMs, offered by both QCDRs and QRs, are, by far, the most commonly available measure. They average seven MIPS CQM measures per MVP with at least four, and at most twelve, choices per MVP.
    • Most Qualified Registries offer any of the available MIPS CQMs.
    • QCDRs tend to be specialty-specific. Medicare permits them to submit MIPS CQMs and their QCDR measures, and most will offer MIPS CQM measures that are wanted or needed by the specialty they serve.
  • The second most common mechanism is eCQM. Two MVPs have no eCQM choices. The average is three, and the range is up to eight.
  • In third place comes Medicare Part B Claims, requiring fake CPT codes, called QDC or Quality Data Codes.
    • Small practices can only use these (those with fifteen or fewer clinicians).
    • Ten of the twelve MVPs have claims measure choices attached to them.
    • There is an average of two choices per measure, with a range of zero at the low end to six per measure at the high end.
    • If you are a small practice choosing claims measures, you don’t have to submit a full complement of four measures if you submit all of the claims choices.
  • In fourth place is QCDR measures. Six MVPs include QCDR choices, and six have none. There is an average of two per MVP, and one of the MVPs has six QCDR measure choices.
  • The CAHPS survey is also an available choice in four MVPs.
  • Finally, even Administrative Claims are represented amongst the MVP quality measure choices.
    • Medicare calculates Administrative Claims measures from practice claims submitted for billing. Two MVPs each include one available Administrative Claims measure.

Question Two: QCDRs vs. Qualified Registries – Performance Rates

Becky’s second question: “I’m curious if we know the performance rates of QCDRs vs. QRs? We want to do a cost/benefit analysis.”

It’s a valuable concept.

You’re essentially asking: “I am delivering excellent performance to my patients. Is a QR or QCDR more likely to appropriately reflect that high performance in the submissions made on my behalf?”

I don’t know of any way to get to that comparison.

There is some indirect data comparing eCQMs with MIPS CQMs. Nearly all eCQMs have an equivalent or near-equivalent measure in the Registry, MIPS CQM measure set. Medicare sets annual benchmarks based on performance rates received and observed in yearly submissions. Benchmarks are typically lower for eCQMs than MIPS CQMs, meaning performance scores are routinely lower for eCQM users than MIPS CQM users.

There could be common causes: factors that lead to the adoption and use of eCQM measures could also predict lower actual performance. But in understanding the nature of documentation standards and workflow requirements and the mechanisms’ requirements to be populated, I suspect that equivalent performance is falsely downgraded by strict measurement requirements and a comparative lack of flexibility of eCQM systems compared to MIPS CQM systems.

There is no such comparison between QCDR and QR processes. They use the same specifications, the rules grant them the same flexibility, and they share benchmarks. The observable differences are in capability, flexibility, and measure choices offered.

QCDRs will likely have fewer choices, less flexibility, and fewer capabilities than QRs:

  • QCDRs generally specialize in a single specialty.
    • They draw from a subset of practices and providers nationally.
    • If you are single-specialty group, a QCDR, tending to be specialty specific, is more likely to meet your needs than the more varied needs in multispecialty groups.
  • QRs, being generalists, draw from the entire pool of practices and providers nationally.

Considering the variety in the existing twelve MVP specification sets and extrapolating forward to an aggressive MVP development process, I expect to see all measure types represented indefinitely going forward.

And, if yours is a multispecialty group, you will likely need mixed submissions drawing on multiple mechanisms.

Question Three: Advice for Improving MIPS Scores

Becky’s third question: “It looks difficult to get each of our measures up to the full potential ten points. What advice do you have for getting there?”

CMS designed the MIPS rules to make it hard. It will be a challenging task to get to the maximum points for all measures.

You are not scored directly on performance. CMS assesses each measure by its modified percentile rank. Only the top percentile of performance rates gets a score of ten. Your practice has to be in the top 1% on each measure to reach the full score.

To be in the top 1% of all practices nationwide will take scrupulous attention to the details. Remember, with grading on a scale, you will compete with many others driven to be in the top percentile. We expect benchmarks to be progressively higher over the years.

On the abovementioned point about scrupulous attention to the details – what are those details?

  • Systematize your excellent care. Make sure that, invariably, the care measured is the care you’re providing. It’s a team process in your practice.
  • You need precise documentation of the care you provide in a way that is accessible to your measurement system.
  • You need to confirm that your measurement system is appropriately interpreting your documentation.
  • You need to monitor your performance metrics regularly.
  • During regular monitoring, self-audit a sampling of each performance category to check your work.
  • And, of course, you should be regularly identifying and correcting deficits.

And this gets us back to your last question about comparing vendors: remember that a vendor who can guide you through this continuous cycle of improvement is your best choice for performing well and achieving high scores.

Question Four: Understanding CAHPS for MIPS Value Pathways (MVPs)

Becky’s final question: “Understanding the CAHPS, if our facilities do CAHPS, how am I to know if that can be a measure for a physician group on the MVPs?”

The CAHPS survey is an option in four of the MVPs available for 2023, and the Emergency Department-focused MVP is one of them.

If your facility is doing CAHPS, there are still a few issues to have in mind while you are considering the use of the measure:

  • The CAHPS option is the “CAHPS for MIPS Clinician/Group Survey” – you’ll need to ensure your facility isn’t using a different survey.
  • The applicable population to the survey for the MVP is the patients attributable to the group using the MVP.
  • There is a minimum sample size that scales with group size. You need to have the case minimum to use CAHPS.
  • Medicare warns that they’ve optimized the CAHPS for MIPS Clinician/Group Survey for primary care. It’s a good idea to ensure you want to be assessed on the matters the survey evaluates.

I suggest you double-check these details in discussion with your facility’s survey vendor, and be sure to include the liaison from your facility who works with the survey vendor. There may be a simple and affordable extension of the scope of the effort that can serve your MVP needs.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, Primary Care First, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.

On LinkedIn, leave your questions in a comment on any of our posts.

And you can reach out directly by sending an email to

Want to learn more about the MIPS program in 2023?

As MIPS becomes more difficult, it's crucial to have a plan in place. We've made a guide that provides an overview of 2023 MIPS requirements and changes to help you and your organization find success in the 2023 Performance Year.

Access the Guide
Get Helpful News & Resources
  • This field is for validation purposes and should be left unchanged.