Merge pull request #753 from CMSgov/2024/QPPA-8499

QPPA-8499: add CAHPS benchmarks
CMSgov · Jan 12, 2024 · b31e4f0 · b31e4f0
2 parents 150535f + 672b356
commit b31e4f0
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Showing 6 changed files with 482 additions and 72 deletions.
diff --git a/benchmarks/2024.json b/benchmarks/2024.json
@@ -4874,6 +4874,231 @@
     },
     "averagePerformanceRate": 3.44
   },
+  {
+    "measureId": "CAHPS_1",
+    "benchmarkYear": 2022,
+    "performanceYear": 2024,
+    "submissionMethod": "certifiedSurveyVendor",
+    "isToppedOut": false,
+    "isHighPriority": true,
+    "isInverse": false,
+    "metricType": "cahps",
+    "isToppedOutByProgram": false,
+    "percentiles": {
+      "1": 63.18,
+      "10": 77.47,
+      "20": 80.27,
+      "30": 82.28,
+      "40": 83.59,
+      "50": 84.49,
+      "60": 85.52,
+      "70": 86.37,
+      "80": 87.14,
+      "90": 88.72,
+      "99": 99
+    },
+    "averagePerformanceRate": null
+  },
+  {
+    "measureId": "CAHPS_11",
+    "benchmarkYear": 2022,
+    "performanceYear": 2024,
+    "submissionMethod": "certifiedSurveyVendor",
+    "isToppedOut": false,
+    "isHighPriority": true,
+    "isInverse": false,
+    "metricType": "cahps",
+    "isToppedOutByProgram": false,
+    "percentiles": {
+      "1": 9.77,
+      "10": 19.43,
+      "20": 21.5,
+      "30": 22.96,
+      "40": 24.12,
+      "50": 25.64,
+      "60": 26.8,
+      "70": 27.99,
+      "80": 29.07,
+      "90": 31.04,
+      "99": 99
+    },
+    "averagePerformanceRate": null
+  },
+  {
+    "measureId": "CAHPS_2",
+    "benchmarkYear": 2022,
+    "performanceYear": 2024,
+    "submissionMethod": "certifiedSurveyVendor",
+    "isToppedOut": false,
+    "isHighPriority": true,
+    "isInverse": false,
+    "metricType": "cahps",
+    "isToppedOutByProgram": false,
+    "percentiles": {
+      "1": 85.18,
+      "10": 91.18,
+      "20": 92.18,
+      "30": 92.75,
+      "40": 93.2,
+      "50": 93.63,
+      "60": 93.99,
+      "70": 94.41,
+      "80": 94.81,
+      "90": 95.3,
+      "99": 99
+    },
+    "averagePerformanceRate": null
+  },
+  {
+    "measureId": "CAHPS_3",
+    "benchmarkYear": 2022,
+    "performanceYear": 2024,
+    "submissionMethod": "certifiedSurveyVendor",
+    "isToppedOut": false,
+    "isHighPriority": true,
+    "isInverse": false,
+    "metricType": "cahps",
+    "isToppedOutByProgram": false,
+    "percentiles": {
+      "1": 82.69,
+      "10": 89.67,
+      "20": 90.54,
+      "30": 91.15,
+      "40": 91.76,
+      "50": 92.27,
+      "60": 92.62,
+      "70": 93.05,
+      "80": 93.48,
+      "90": 94.02,
+      "99": 99
+    },
+    "averagePerformanceRate": null
+  },
+  {
+    "measureId": "CAHPS_4",
+    "benchmarkYear": 2022,
+    "performanceYear": 2024,
+    "submissionMethod": "certifiedSurveyVendor",
+    "isToppedOut": false,
+    "isHighPriority": true,
+    "isInverse": false,
+    "metricType": "cahps",
+    "isToppedOutByProgram": false,
+    "percentiles": {
+      "1": 62.71,
+      "10": 71.28,
+      "20": 73.32,
+      "30": 74.62,
+      "40": 75.9,
+      "50": 77.19,
+      "60": 78.09,
+      "70": 79.38,
+      "80": 80.52,
+      "90": 82.05,
+      "99": 99
+    },
+    "averagePerformanceRate": null
+  },
+  {
+    "measureId": "CAHPS_5",
+    "benchmarkYear": 2022,
+    "performanceYear": 2024,
+    "submissionMethod": "certifiedSurveyVendor",
+    "isToppedOut": false,
+    "isHighPriority": true,
+    "isInverse": false,
+    "metricType": "cahps",
+    "isToppedOutByProgram": false,
+    "percentiles": {
+      "1": 41.59,
+      "10": 56.68,
+      "20": 58.78,
+      "30": 60.28,
+      "40": 61.45,
+      "50": 62.73,
+      "60": 63.87,
+      "70": 65.12,
+      "80": 66.17,
+      "90": 67.67,
+      "99": 99
+    },
+    "averagePerformanceRate": null
+  },
+  {
+    "measureId": "CAHPS_6",
+    "benchmarkYear": 2022,
+    "performanceYear": 2024,
+    "submissionMethod": "certifiedSurveyVendor",
+    "isToppedOut": false,
+    "isHighPriority": true,
+    "isInverse": false,
+    "metricType": "cahps",
+    "isToppedOutByProgram": false,
+    "percentiles": {
+      "1": 45.26,
+      "10": 55.05,
+      "20": 57.43,
+      "30": 58.83,
+      "40": 60,
+      "50": 61.08,
+      "60": 62.41,
+      "70": 63.45,
+      "80": 64.62,
+      "90": 66.5,
+      "99": 99
+    },
+    "averagePerformanceRate": null
+  },
+  {
+    "measureId": "CAHPS_8",
+    "benchmarkYear": 2022,
+    "performanceYear": 2024,
+    "submissionMethod": "certifiedSurveyVendor",
+    "isToppedOut": false,
+    "isHighPriority": true,
+    "isInverse": false,
+    "metricType": "cahps",
+    "isToppedOutByProgram": false,
+    "percentiles": {
+      "1": 72.67,
+      "10": 82.18,
+      "20": 83.39,
+      "30": 84.33,
+      "40": 85.23,
+      "50": 85.72,
+      "60": 86.32,
+      "70": 86.89,
+      "80": 87.47,
+      "90": 88.1,
+      "99": 99
+    },
+    "averagePerformanceRate": null
+  },
+  {
+    "measureId": "CAHPS_9",
+    "benchmarkYear": 2022,
+    "performanceYear": 2024,
+    "submissionMethod": "certifiedSurveyVendor",
+    "isToppedOut": false,
+    "isHighPriority": true,
+    "isInverse": false,
+    "metricType": "cahps",
+    "isToppedOutByProgram": false,
+    "percentiles": {
+      "1": 81.19,
+      "10": 89.03,
+      "20": 90.32,
+      "30": 91.26,
+      "40": 91.87,
+      "50": 92.38,
+      "60": 92.92,
+      "70": 93.35,
+      "80": 93.86,
+      "90": 94.58,
+      "99": 99
+    },
+    "averagePerformanceRate": null
+  },
   {
     "measureId": "CAP22",
     "benchmarkYear": 2022,
@@ -5824,4 +6049,4 @@
     },
     "averagePerformanceRate": 76.4
   }
-]
+]
diff --git a/package-lock.json b/package-lock.json
diff --git a/staging/2024/benchmarks/benchmarks.csv b/staging/2024/benchmarks/benchmarks.csv
@@ -158,7 +158,7 @@ Controlling High Blood Pressure,236,Medicare Part B Claims,Intermediate Outcome,
 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention,226,eCQM,Process,31.5126302907081,59.25,No,No,1.92,13.7,25.0,36.92,50.0,62.5,74.95,85.75,93.34,98.44,100.0,N,N,multiPerformanceRate
 Functional Status Change for Patients with Low Back Impairments,220,MIPS CQM,Patient-Reported Outcome-Based Performance Measure (PRO-PM),21.560300707008462,74.02,No,No,29.71,45.98,53.02,58.18,67.97,75.3,81.36,93.55,100.0,100.0,100.0,Y,N,singlePerformanceRate
 Controlling High Blood Pressure,236,MIPS CQM,Intermediate Outcome,20.10530707643529,71.26,No,No,1.0,10.0,20.0,30.0,40.0,50.0,60.0,70.0,80.0,90.0,99.0,Y,N,singlePerformanceRate
-Use of High-Risk Medications in Older Adults,238,eCQM,Process,6.222023883830705,5.10,Yes,Yes,0.0,0.0,0.0,0.13,1.31,3.17,4.8,6.9,9.56,13.43,24.67,Y,Y,multiPerformanceRate
+Closing the Referral Loop: Receipt of Specialist Report,374,eCQM,Process,28.18081523084144,45.63,No,No,0.73,8.33,18.61,27.38,35.17,43.02,51.3,60.19,72.09,89.29,100.0,Y,N,singlePerformanceRate
 Barrett's Esophagus,249,Medicare Part B Claims,Process,0.0,100.00,Yes,Yes,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate
 Radical Prostatectomy Pathology Reporting,250,Medicare Part B Claims,Process,0.0,100.00,Yes,Yes,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate
 Childhood Immunization Status,240,eCQM,Process,18.115059432448273,25.53,No,No,1.0,4.76,7.84,12.16,16.67,22.61,28.17,35.48,42.18,50.0,73.77,N,N,singlePerformanceRate
@@ -176,12 +176,10 @@ Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT
 Depression Remission at Twelve Months,370,eCQM,Outcome,12.058926514185961,12.33,No,No,0.48,2.08,3.5,4.96,6.93,8.945,10.89,14.0,18.16,25.0,54.1,Y,N,multiPerformanceRate
 Unplanned Reoperation within the 30 Day Postoperative Period,355,MIPS CQM,Outcome,8.815421499789114,1.59,No,No,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.81,1.8,35.82,Y,Y,singlePerformanceRate
 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment,382,eCQM,Process,31.765420463583677,39.11,No,No,0.46,2.27,5.81,13.53,20.62,34.88,46.94,59.68,67.95,88.09,100.0,Y,N,singlePerformanceRate
-Closing the Referral Loop: Receipt of Specialist Report,374,MIPS CQM,Process,23.583173483331276,88.68,Yes,Yes,4.76,47.9,85.66,96.43,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate
 Adherence to Antipsychotic Medications For Individuals with Schizophrenia,383,MIPS CQM,Intermediate Outcome,19.5841856572374,94.09,No,No,6.25,93.75,94.34,99.34,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate
 Children Who Have Dental Decay or Cavities,378,eCQM,Outcome,26.747750960194228,28.68,No,No,0.0,0.0,0.9,3.64,9.19,29.01,34.33,45.09,48.63,66.06,79.07,Y,Y,singlePerformanceRate
 Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery,384,MIPS CQM,Outcome,9.054155983107913,93.14,Yes,Yes,67.57,79.17,84.0,90.48,95.83,97.62,99.35,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate
 Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery,385,MIPS CQM,Outcome,21.032802408211253,55.95,No,No,10.87,22.31,34.55,53.27,56.63,58.945,62.68,65.2,70.21,75.0,100.0,Y,N,singlePerformanceRate
-Closing the Referral Loop: Receipt of Specialist Report,374,eCQM,Process,28.18081523084144,45.63,No,No,0.73,8.33,18.61,27.38,35.17,43.02,51.3,60.19,72.09,89.29,100.0,Y,N,singlePerformanceRate
 "Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists",379,eCQM,Process,6.955183495821311,4.37,No,No,0.01,0.05,0.235,0.49,0.995,1.73,3.12,4.58,6.94,11.03,33.74,N,N,singlePerformanceRate
 Functional Status Assessment for Total Hip Replacement,376,eCQM,Process,18.389424358047176,17.04,No,No,0.51,1.3,2.45,7.065,9.92,11.68,14.115,18.375,25.37,43.085,98.33,Y,N,singlePerformanceRate
 Immunizations for Adolescents,394,MIPS CQM,Process,20.438823361645984,30.75,No,No,1.06,10.96,15.79,20.0,23.08,26.67,30.56,33.55,40.0,53.85,100.0,N,N,multiPerformanceRate

diff --git a/staging/2024/benchmarks/benchmarks_cahps.csv b/staging/2024/benchmarks/benchmarks_cahps.csv
@@ -0,0 +1,10 @@
+measureName,measureId,submissionMethod,measureType,benchmark,isToppedOut,isToppedOutByProgram,percentile1,percentile10,percentile20,percentile30,percentile40,percentile50,percentile60,percentile70,percentile80,percentile90,percentile99,isHighPriority,isInverse,metricType,averagePerformanceRate
+CAHPS for MIPS SSM: Stewardship of Patient Resources,CAHPS_11,CAHPS Survey Vendor,Patient Engagement/Experience,Y,N,,9.77,19.43,21.5,22.96,24.12,25.64,26.8,27.99,29.07,31.04,99,Y,,cahps,
+CAHPS for MIPS SSM: Patient's Rating of Provider,CAHPS_3,CAHPS Survey Vendor,Patient Engagement/Experience,Y,N,,82.69,89.67,90.54,91.15,91.76,92.27,92.62,93.05,93.48,94.02,99,Y,,cahps,
+"CAHPS for MIPS SSM: Getting Timely Care, Appointments and Information",CAHPS_1,CAHPS Survey Vendor,Patient Engagement/Experience,Y,N,,63.18,77.47,80.27,82.28,83.59,84.49,85.52,86.37,87.14,88.72,99,Y,,cahps,
+CAHPS for MIPS SSM: How Well Providers Communicate,CAHPS_2,CAHPS Survey Vendor,Patient Engagement/Experience,Y,N,,85.18,91.18,92.18,92.75,93.20,93.63,93.99,94.41,94.81,95.3,99,Y,,cahps,
+CAHPS for MIPS SSM: Care Coordination,CAHPS_8,CAHPS Survey Vendor,Patient Engagement/Experience,Y,N,,72.67,82.18,83.39,84.33,85.23,85.72,86.32,86.89,87.47,88.1,99,Y,,cahps,
+CAHPS for MIPS SSM: Courteous and Helpful Office Staff,CAHPS_9,CAHPS Survey Vendor,Patient Engagement/Experience,Y,N,,81.19,89.03,90.32,91.26,91.87,92.38,92.92,93.35,93.86,94.58,99,Y,,cahps,
+CAHPS for MIPS SSM: Health Promotion and Education,CAHPS_5,CAHPS Survey Vendor,Patient Engagement/Experience,Y,N,,41.59,56.68,58.78,60.28,61.45,62.73,63.87,65.12,66.17,67.67,99,Y,,cahps,
+CAHPS for MIPS SSM: Shared Decision-Making,CAHPS_6,CAHPS Survey Vendor,Patient Engagement/Experience,Y,N,,45.26,55.05,57.43,58.83,60,61.08,62.41,63.45,64.62,66.5,99,Y,,cahps,
+CAHPS for MIPS SSM: Access to Specialists,CAHPS_4,CAHPS Survey Vendor,Patient Engagement/Experience,Y,N,,62.71,71.28,73.32,74.62,75.9,77.19,78.09,79.38,80.52,82.05,99,Y,,cahps,
diff --git a/staging/2024/benchmarks/json/benchmarks.json b/staging/2024/benchmarks/json/benchmarks.json
@@ -3975,29 +3975,29 @@
     "averagePerformanceRate": 71.26
   },
   {
-    "measureId": "238",
+    "measureId": "374",
     "benchmarkYear": 2022,
     "performanceYear": 2024,
     "submissionMethod": "electronicHealthRecord",
-    "isToppedOut": true,
+    "isToppedOut": false,
     "isHighPriority": true,
-    "isInverse": true,
-    "metricType": "multiPerformanceRate",
-    "isToppedOutByProgram": true,
+    "isInverse": false,
+    "metricType": "singlePerformanceRate",
+    "isToppedOutByProgram": false,
     "percentiles": {
-      "1": 0,
-      "10": 0,
-      "20": 0,
-      "30": 0.13,
-      "40": 1.31,
-      "50": 3.17,
-      "60": 4.8,
-      "70": 6.9,
-      "80": 9.56,
-      "90": 13.43,
-      "99": 24.67
+      "1": 0.73,
+      "10": 8.33,
+      "20": 18.61,
+      "30": 27.38,
+      "40": 35.17,
+      "50": 43.02,
+      "60": 51.3,
+      "70": 60.19,
+      "80": 72.09,
+      "90": 89.29,
+      "99": 100
     },
-    "averagePerformanceRate": 5.1
+    "averagePerformanceRate": 45.63
   },
   {
     "measureId": "249",
@@ -4424,31 +4424,6 @@
     },
     "averagePerformanceRate": 39.11
   },
-  {
-    "measureId": "374",
-    "benchmarkYear": 2022,
-    "performanceYear": 2024,
-    "submissionMethod": "registry",
-    "isToppedOut": true,
-    "isHighPriority": true,
-    "isInverse": false,
-    "metricType": "singlePerformanceRate",
-    "isToppedOutByProgram": true,
-    "percentiles": {
-      "1": 4.76,
-      "10": 47.9,
-      "20": 85.66,
-      "30": 96.43,
-      "40": 100,
-      "50": 100,
-      "60": 100,
-      "70": 100,
-      "80": 100,
-      "90": 100,
-      "99": 100
-    },
-    "averagePerformanceRate": 88.68
-  },
   {
     "measureId": "383",
     "benchmarkYear": 2022,
@@ -4549,31 +4524,6 @@
     },
     "averagePerformanceRate": 55.95
   },
-  {
-    "measureId": "374",
-    "benchmarkYear": 2022,
-    "performanceYear": 2024,
-    "submissionMethod": "electronicHealthRecord",
-    "isToppedOut": false,
-    "isHighPriority": true,
-    "isInverse": false,
-    "metricType": "singlePerformanceRate",
-    "isToppedOutByProgram": false,
-    "percentiles": {
-      "1": 0.73,
-      "10": 8.33,
-      "20": 18.61,
-      "30": 27.38,
-      "40": 35.17,
-      "50": 43.02,
-      "60": 51.3,
-      "70": 60.19,
-      "80": 72.09,
-      "90": 89.29,
-      "99": 100
-    },
-    "averagePerformanceRate": 45.63
-  },
   {
     "measureId": "379",
     "benchmarkYear": 2022,