A B C D
Measure Characteristics 2017 2018 P-value 2019 P-value 2020 P-value
(n=193) (n=210) (n=208) (n=194)
Count (%)
A. Quality Measure Types
Structure 2 1.0 1 0.5 0.000 1 0.5 0.000 1 0.5 0.000
Process 173 89.6 197 93.8 195 93.8 182 93.8
Outcome 5 2.6 2 1.0 1 0.5 1 0.5
Intermediate Outcomes 10 5.2 7 3.3 8 3.8 8 4.1
Patient-Reported Outcomes 0 0.0 0 0.0 1 0.5 1 0.5
Efficiency 3 1.6 3 1.4 2 1.0 1 0.5
B. NQS Domains
Effective Clinical Care 53 27.5 55 26.2 0.258 48 23.1 0.000 42 21.6 0.028
Efficiency and Cost Reduction 7 3.6 8 3.8 8 3.8 7 3.6
Patient Safety 36 18.7 45 21.4 46 22.1 46 23.7
Communication and Care Coordination 30 15.5 38 18.1 38 18.3 35 18.0
Person- and Caregiver-centered Experience and Outcomes 9 4.7 8 3.8 8 3.8 4 2.1
Community and Population Health 58 30.1 56 26.7 60 28.8 60 30.9
C. Select MIPS Specialties
Cardiology 8 4.1 8 3.8 0.000 7 3.4 0.000 7 3.6 0.000
Diagnostic Radiology 8 4.1 8 3.8 8 3.8 8 4.1
Emergency Medicine 10 5.2 7 3.3 7 3.4 4 2.1
Family Medicine 21 10.9 25 11.9 25 12.0 24 12.4
Hospitalists 8 4.1 4 1.9 4 1.9 3 1.5
Internal Medicine 20 10.4 20 9.5 22 10.6 21 10.8
Mental Health 7 3.6 6 2.9 6 2.9 6 3.1
Neurology 9 4.7 9 4.3 11 5.3 11 5.7
Obstetrics/Gynecology 12 6.2 13 6.2 14 6.7 14 7.2
Ophthalmology 10 5.2 8 3.8 7 3.4 6 3.1
Otolaryngology 9 4.7 13 6.2 13 6.3 12 6.2
Pathology 8 4.1 8 3.8 5 2.4 5 2.6
Physical Medicine 8 4.1 10 4.8 10 4.8 8 4.1
Preventive Medicine 14 7.3 17 8.1 17 8.2 17 8.8
Urology 6 3.1 10 4.8 10 4.8 9 4.6
General Surgery 7 3.6 8 3.8 8 3.8 7 3.5
Orthopedic Surgery 8 4.1 15 7.1 15 7.2 13 6.6
Plastic Surgery 7 3.6 5 2.4 5 2.4 5 2.5
Thoracic Surgery 7 3.6 7 3.3 6 2.9 6 3.0
Vascular Surgery 6 3.1 9 4.3 8 3.8 8 4.0