Benchmark

Why Benchmarks Matter

In healthcare quality programmes, absolute performance rates mean little without context. A practice reporting a 72% A1C control rate appears to be doing well — but if the national 75th percentile is 78%, that practice is actually underperforming relative to its peers in MIPS decile scoring. Benchmarks transform individual performance data into competitive intelligence and determine payment consequences.

NCQA HEDIS Benchmarks

NCQA publishes annual HEDIS benchmarks derived from all reporting health plans in the United States. For each HEDIS measure, NCQA reports performance at the following percentiles:

• 25th percentile (Low): 25% of plans perform at or below this rate
• 50th percentile (Median): Midpoint of the national distribution
• 75th percentile (High): Top quartile threshold
• 90th percentile (Excellent/High Performance): Top decile — used as the "high performance" target in many quality contracts

MIPS National Benchmarks

CMS publishes MIPS benchmark performance rates for each quality measure, derived from the prior year's reporting data. These benchmarks define the decile ranges (1st through 10th decile) that determine how many points (1–10) a given performance rate earns. The benchmark publication is crucial — a measure where the 90th percentile threshold is 85% requires a higher absolute performance rate to achieve top decile than a measure where the 90th percentile is 65%.

Specialty-Specific Benchmarking

Specialty benchmarks are critical for meaningful comparison. A cardiologist's E&M code distribution should be benchmarked against cardiology peers, not primary care averages. Similarly, a hospital's readmission rate for cardiac surgery patients should be benchmarked against cardiac surgery programmes, not general medical surgical readmission averages. CMS, MGMA, AMGA, and speciality societies all publish specialty-specific benchmark datasets for key operational and clinical metrics.