Mastery of Breast Surgery℠ Program

Background & History


What is this program and why was it developed?

The program is intended to help surgeons document their clinical performance of breast procedures, as well as their care of breast cancer patients and patients at risk for breast cancer.  It includes modules on surgery, percutaneous breast procedures, cancer, risk assessment and diagnostic imaging.  There are varying levels of participation in each module. The levels of participation and the modules used can be changed by the user at any time.

The program was developed in response to the need to document quality outcomes in patient care, and for individual surgeons to know and be able to report their performance. The goal of this program is to provide the surgeon with the tools to meet this challenge via a voluntary reporting system, open to all surgeons, to report on all breast surgical procedures for both benign and malignant disease.

What does the program do for me? Why would I voluntarily participate?

The program will provide you with the opportunity to participate in a data collection/self-review process. This self-reporting process is a fundamental first step in improving quality. Participation now, before such reporting programs become mandatory from outside agencies, will provide you, the surgeon, with the experience of self-reporting and, subsequently, the knowledge about your individual practice and patient outcomes.

The program has been listed as an accepted quality initiative under the ABS Maintenance of Certification (MOC) Part 4 – Evaluation of performance in practice. Part 4 of MOC requires evaluation of performance in practice through participation in quality improvement programs.  For information on the American Board of Surgery MOC go to www.absurgery.org.

If you elect to participate in the Mastery Program’s QCDR, you may be able to avoid the -4.0% MIPS 2019 payment adjustment which is based on successful MIPS reporting during the 2017 program year.  Please note that the Society is only participating in the Quality Component of the MIPS program, which is 60% of the MIPS performance score.

For more detailed information on MIPS reporting through the Mastery program click here.

Who is eligible to participate in the program?

Participation in the Mastery of Breast Surgery℠ program is offered at no cost to surgeons who are members of the American Society of Breast Surgeons.

Will this help me with American Board of Surgery recertification and maintenance of competence? Will this help me with my hospital credentials?

Although no one can speak for other outside organizations, it is anticipated that this program will be valued by other entities as evidence of continuing medical education and commitment to individual quality assessment and improvement.

The American Board of Surgery has recognized the Mastery of Breast Surgery℠ Program as an accepted quality initiative under the ABS Maintenance of Certification (MOC) Part 4 – Evaluation of performance in practice. Part 4 of MOC requires evaluation of performance in practice through participation in quality improvement programs.

How does this program relate to other programs that propose to improve the quality of care for breast patients, such as those from the NCBC or the NAPBC?

This program is designed for the individual surgeon, and is therefore fundamentally different from the center accreditation concept. There is every intention, however, to avoid duplication of reporting whenever possible, and to work collaboratively with other organizations interested in quality care. It is intended that this program will improve the quality of breast care provided by the surgeon regardless of practice setting or location.

What is the cost of enrollment – both the direct and indirect costs (such as my staff time)?

Participation in the program is free to members of the Society. As the program develops there may be some administrative and/or data management fees that may be passed on to you, but we are committed to creating an affordable and user-friendly program. We plan to make data collection and entry easy and accessible on the Internet.

Who will have access to the data? Will other surgeons, insurance companies or the public have access to it?

Your data will be regarded as strictly confidential and can only be viewed by you under the program. You will be able to compare your data with the entire group, or with surgeons who are similar to you in terms of practice type and location. Only the de-identified data will be available to the Society staff and appropriate Committee and Board members. The Society will not make individual surgeon data available to the public, insurance companies, advocacy groups, credentialing bodies, or any other interested parties except in strict accordance with the Business Associate Agreement that you must sign to participate in the program. You should note, however, that the Society cannot guarantee that it will not be forced to release data, including individual surgeon data, requested under the compulsion of a legally enforceable subpoena, search warrant, or court order.

Registry data (including personal health information of non-Medicare patients) may be inspected by CMS under their oversight authority for those surgeons who chose to participate in the QCDR registry component of the program.

What new quality measures are being planned?

The Patient Safety and Quality Committee of the Society has studied and identified many quality measures that can be linked to quality breast care. Feedback from you and the other participants will help to build this program including the addition of future quality measures.

Let Us Know What You Think

We are interested to know what you think about this important initiative. We want to answer any questions you may have. Most important, we need your input and participation to make this program successful. Please contact us at mastery@breastsurgeons.org.

The American Society of Breast Surgeons
10330 Old Columbia Road, Suite 100
Columbia, MD 21046 

Phone: 410-381-9500/877-992-5470
Fax: 410-381-9512
mastery@breastsurgeons.org