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Published: August 17, 2021

Physician Practices Needed to Help Test New Clinical Quality Measure

Quality Improvement Opportunity: COVID-19 Vaccination by Clinicians

The Centers for Medicare & Medicaid Services (CMS) in partnership with Mathematica is recruiting physician practices and registries to help test the feasibility of a new clinical quality measure (CQM), COVID-19 Vaccination by Clinicians to develop and maintain quality measures for CMS’s Merit-based Incentive Payment System (MIPS). CMS is offering up to $2,000 to your organization for participating and plans to conduct testing between July and September 2021.

Measure Details: The COVID-19 Vaccination by Clinicians measure is in development for eligible clinicians, and it assesses the percent of patients age 18 or older who have ever completed a full COVID-19 vaccination series.

Testing Details: We are seeking practices and registries to participate in a workflow assessment to help our team learn about processes related to the proposed measure.

Participants are expected to:

  1. For physician practices, have knowledge and use of the COVID-19 vaccination workflow and clinical /EHR documentation, or knowledge and use of workflows and clinical/EHR documentation for other vaccinations
  2. For registries, have experience collecting data from clinicians on the COVID-19 vaccination or other vaccinations
  3. Have prior experience reporting to MIPS

CMS is particularly interested in test sites that are also able to participate in future efforts to test the measure for scientific acceptability. These efforts would entail the test site providing Mathematica with de-identified patient-level data on COVID vaccinations, as well as other data to allow Mathematica to construct clinician scores on the measure. Sites would receive additional compensation for participating in testing for scientific acceptability.

Benefits for participating practices and registries

  • Participating organizations, also known as test sites, will receive an incentive payment. A test site is defined as an entity that participates in a workflow assessment.
  • Test site staff will gain insight into quality measurement that could help your organization refine its internal efforts to improve quality.
  • Test site staff will help provide insight for a CQM that CMS may use in its quality-reporting programs.

If your team would like to participate in the measure testing opportunity, please email Jessica Saddler (jsaddler@mathematica-mpr.com).


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