MIPS 001 · Diabetes: HbA1c poor control (>9%)
294 met, 117 gap, of 411 read; 1 not yet read
71.5%
Patients 18 to 75 with diabetes whose most recent HbA1c in the year is at or below 9. No result in the year counts as poor control.
Six measures an ACO is scored on or exposed to, read directly from each practice’s EHR through one approved app. Rates carry their denominators; hover any cell. Click a column to put the practice that needs the call at the top.
One row is synthetic. Practice B is not a real practice. It is a fixed transform of the real row so the table has a shape before a second practice is activated, and nothing on it should be quoted. It is removed the day real data replaces it.
| Practice | ||||||
|---|---|---|---|---|---|---|
| Lubbock Primary Care | 91.5% | 70.0% | 4.6% | +29.8 pts | 245 | 240 |
| Practice Bsynthetic | 71.0% | 38.0% | 14.0% | +1.2 pts | 9 | 384 |
Labs and vitals for every Medicare-class patient with diabetes or hypertension on the problem list, scored the way MIPS scores them. A result done in the office counts the day it is resulted, which a claims feed cannot see. Lubbock Primary Care, 1,453 patients in at least one denominator, as of 2026-09-06.
Patients 18 to 75 with diabetes whose most recent HbA1c in the year is at or below 9. No result in the year counts as poor control.
Patients 18 to 85 with diabetes who had both an eGFR and a urine albumin-creatinine ratio in the year. The uACR is the one that gets missed.
Patients 18 to 85 with hypertension whose most recent blood pressure in the year is below 140/90.
Not shown, because eCW does not expose them to this app yet: breast and colorectal cancer screening, immunizations, diabetic eye exams, depression screening.
Attribution runs through primary-care services, and the wellness visit is the one a Medicare patient reliably gets each year. A patient with no AWV is a quality miss this year and an attribution risk next year.
Enrolled chronic patients cost less. Every qualifying patient outside a program is unmanaged utilization landing in the benchmark.
The practice did the work and nobody was paid. Leakage is the gap between the program a practice runs and the one the ACO can point to.
A code's share of a program moving twenty points in a month is either a deliberate change or a configuration change nobody reviewed. An auditor sees the same chart a year later; the ACO should see it first.
Level is a definition, not a judgment. Level 1 for a patient with three chronic conditions is money left behind; level 3 without QMB status is money that may have to go back.
E11.9 with documented complications is a risk score understated. Nothing in fee-for-service pays for the fix; the benchmark does.