2023 # 483 Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)

CMS Measure ID: #483

Collection Type: CQM

Reporting Frequency: Once per patient per year

Outcome: Yes

High Priority: Yes

NQS Domain: Person and Caregiver-Centered Experience Outcomes

Measure Age: New

Instructions

This measure is to be submitted once per performance period. For each MIPS eligible clinician, group, subgroup*, virtual group, and APM Entity, a minimum of 30 PCPCM PRO instruments per clinician are needed for submission of this measure. All valid survey results (as defined in the specification) should be included in the aggregate score. For MIPS eligible groups, subgroups*, virtual groups, and APM entities with 5 or more clinicians, a minimum of 150 PCPCM PRO instruments per TIN for each site/location associated with the clinicians’ part of the group, subgroups*, virtual groups, and APM entities are needed for submission of this measure. If the MIPS eligible group, subgroup*, virtual group, and APM entity with 5 or more clinicians encompasses multiple sites/locations, each site/location would need to meet the PCPCM PRO instruments requirements as stated.

NOTE: Data for the measure are collected using the PCPCM PRO instrument. The target population is all active patients attributed to the clinician or practice. Every active patient receives an invitation to complete the PCPCM PROM during their birth month. A patient is defined as active if the patient has had a documented interaction with the practice within 12 months of their birth month during the measurement period.

*Subgroups are only available through MVP reporting. All measure-specific criteria must be met by the subgroup.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

Description

The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM Patient Reported Outcome Measure (PROM) a comprehensive and parsimonious set of 11 patient-reported items – to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient’s relationship with the clinician or practice.

Denominator

Total number of completed PCPCM PRO instruments received in the reporting period.

Definitions:
A completed PCPCM PRO instrument – A PCPCM PRO instrument for which the patient has responded to at least 8 of 11 items.
Active patient – The patient has had a documented interaction with the practice within 12 months of their birth month during the measurement period.

DENOMINATOR NOTE: The target population is all active patients attributed to a clinician or practice during the performance reporting period who had a documented interaction within the 12 months prior to the patient’s birth month. The target population is defined the same, regardless of unit of analysis (clinician, practice, or system).

The PCPCM PRO is the same for all patients, regardless of age. Because the PCPCM PRO applies to all patients and is not particular to a clinical encounter, it is administered once a year to each patient during their birth month. All surveys received during the measurement period should be counted.

For each MIPS eligible clinician, group, subgroup*, virtual group, and APM Entity, a minimum of 30 PCPCM PRO instruments per clinician are needed for submission of this measure. For MIPS eligible groups, subgroups*, virtual groups, and APM entities with 5 or more clinicians, a minimum of 150 PCPCM PRO instruments per TIN for each site/location associated with the clinicians’ part of the group, subgroups*, virtual groups, and APM entities are needed for submission of this measure. If the MIPS eligible group, subgroup*, virtual group, and APM entity with 5 or more clinicians encompasses multiple sites/locations, each site/location would need to meet the PCPCM PRO instruments requirements as stated.

*Subgroups are only available through MVP reporting. All measure-specific criteria must be met by the subgroup.

Table 1- PCPCM PRO instrument questions

Denominator Criteria (Eligible Cases):

Numerator

The calculated PCPCM PRO-PM performance score

NUMERATOR NOTE: Scoring for the PCPCM PRO-PM is completed through a simple 4 step process using the PCPCM PRO to assess the broad scope of primary care from a patient’s perspective.

• Step One: Exclude incomplete patient responses. Any PCPCM PRO instrument for which a patient failed to answer at least 8 of the 11 items is excluded from calculations.

• Step Two: Calculate PCPCM PRO item specific mean scores. Patients choose one of four response options for each item in the PCPCM PRO instrument. In scoring the PCPCM PRO, the first step requires determining an item mean score for each of the 11 items. Since the instrument scale is word based – Definitely, Mostly, Somewhat, Not At All – each response option must be assigned a value. Values are assigned as follows: Definitely = 4, Mostly = 3, Somewhat = 2, Not At All = 1.

Calculating the mean score for each item then requires looking across all PCPCM PRO instruments received for the entity being assessed during the analysis period. For example, if the entity is a clinician, then all completed (see Step One) PCPCM PRO instruments collected for that clinician are included in the calculation. If the entity is a practice, then all PCPCM PRO instruments collected for that practice are included in the analysis

An entity’s score for each PCPCM PRO item is calculated as a mean, i.e., the summary of all responses across PCPCM PRO instruments received for the entity, divided by the number of instruments received. This process leads to 11 item specific PCPCM PRO scores. Means should be reported to two decimal points.

• Step Three: Calculate the PCPCM PRO total score. The PCPCM PRO total score for the entity is calculated by determining the mean of the 11 scored PRO items. This is done by adding the mean scores of all 11 PRO items and then dividing by 11. PRO means should be reported to two decimal points.

• Step Four: Converting PCPCM PRO total scores and to PCPCM PRO-PM performance score. In order to use the PCPCM PRO as a performance measure for reporting, the 4 point PCPCM PRO scale must be converted to a 0-100 performance scale. To do this, the PCPCM PRO total score for an entity, as calculated in Step Three, is divided by 4 and then multiplied by 100.