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Between the release of the 2021 proposed rule and the release of the 2022 final rule, CMS managed to introduce, backtrack, and ultimately postpone several policies that will greatly impact most Medicare Shared Savings Program (MSSP) ACOs. After considerable back-and-forth policy making, the 2022 Physician fee schedule final rule settled on an extended timeline for MSSP ACOs to transition to a more holistic approach for managing quality and cost for their entire patient population.
A new kind of programmatic driver under the MSSP ACO program is the ‘quality performance standard’, which was a new standard for MSSP ACOs starting in 2021. The quality performance standard is the minimum performance level ACOs must achieve in order to share in any savings earned, avoid maximum shared losses under certain payment tracks, and avoid quality-related compliance actions.[1] Essentially, when the quality performance standard is met, ACOs are eligible to share in savings at the maximum sharing rate and (for ACOs in two-sided models) share in losses based on their quality score (or at a fixed percentage based on track). This means losses could be substantially less if the quality scores are higher.
At a macro view, the quality performance standard is intended to set certain criteria and collective goals to continue pushing the MSSP ACO program towards the loftier ambitions of “achieving better health for individuals, better population health, and lowering growth in expenditures.”[1] While the larger program goals seem reasonable, the mechanics to reach them can be a challenge to all sizes and types of active MSSP ACOs. The impact of the quality performance standard will be revisited after discussing some of the technical challenges ACOs will face in the coming years.
One of the biggest challenges MSSP ACOs will face in the next four years revolves around quality reporting requirements for the program but the implications of this challenge extend far beyond just quality reporting. In the 2022 final rule, CMS finalized that the CMS Web Interface (CMS WI) will remain as a quality reporting option for MSSP ACOs in performance years 2022, 2023 and 2024. Beginning with the 2025 performance year, MSSP ACOs will be required to report on MIPS Clinical Quality Measures (MIPS CQMs) or electronic Clinical Quality Measures (eCQMs) to reach the quality performance standard.
Retiring the CMS WI quality collection method and reporting option means that MSSP ACOs will have to report on all payer patients on a set of MIPS CQMs/eCQMs. ACOs that have focused maximum efforts on accountability for Medicare beneficiaries will need to start focusing on all-payer beneficiaries as they will begin to carry weight on determining an MSSP’s total shared savings or losses. This point will later be elaborated with further clarity.
The more technical challenge introduced by the retirement of the CMS WI quality reporting method is the move to report all payer patients on a set of MIPS CQM/eCQM quality measures, which means different things for different ACO operations. ACOs made up of practices and providers using a single instance for their billing (PM) and clinical (EHR) system may not have the difficulty that larger ACOs with multiple participants on multiple different Payment Systems (PM)/Certified EHR Technology (CEHRT) systems will face. Since true interoperability between the multitude of available PM and EHR technology brands/models remains a challenge, this requirement to aggregate data for all payer patients across all ACO participants (and systems) poses a significant set of challenges for the MSSP ACO community.
Consider a scenario of different participant TINs within a single ACO, which uses the same brand/model for their Payment PM and/or CEHRT. Even using the same system rarely means they share the same instance of that system meaning all data from all instances still needs to be ingested and then aggregated together into a single set of quality measure results to submit to CMS for the quality reporting requirement.
Another of the many interoperability difficulties that ACOs will face is the ability to patient match across multiple different systems. Sometimes even a single practice that uses a different system for billing than for their clinical data can have different patient identifiers in each system. Consider an ACO made up of several different TINs using several different PM and/or EHR system.
The requirement to report on all payer patients also requires the capability of patient matching across all systems to create a single patient entity that can then be aggregated up for the ACO to be able to submit a single set of quality measure results to CMS to meet the quality reporting requirement and hopefully the quality performance standard.
Now that we’ve pointed out some of the technical challenges of reporting aggregated data on all payer patients across an entire ACO, let’s revisit the quality performance standard to understand the significance of that quality reporting on the ultimate success of sharing in savings or the fate of having to pay CMS back in losses. For 2022 and 2023 there are two ways an organization can reach the quality performance standard. One method means that the ACO won’t find out if they reached the quality performance standard until between 7 to 12 months after the actual performance year occurred. The other way gives the ACO a bit more control over actually reaching the quality performance standard during the current and active performance year.
The first method to reach the quality performance standard requires that ACOs report the APM Performance Pathway measures and then wait 7 to 12 months to find out if they reached the quality performance standard when CMS releases the final scoring information. The requirement to reach the quality performance standard is that the ACO achieves a quality performance score equivalent to or higher than the 30th percentile across all MIPS quality performance category scores. All MIPS quality category scores won’t be calculated and finalized until roughly July (and in some cases, later) of the year following the performance year. This means, the ACO has no control over their ability to meet the target and therefore share in savings and avoid the maximum loss rate.
For the second method Knowledge is key, which is why CMS presented another option of reporting where ACOs can ascertain if they are reaching the quality performance standard within the actual performance year and not 7 to 12 months after. This option of reporting all payer patients on MIPS CQMs/eCQMs means ACOs will know the target performance to work toward because CMS releases the benchmarks just prior to the actual performance period. Known targets enable ACOs to modify behaviors and improve workflows when the changes they make can still impact their ultimate shared savings/losses for that year. However, this option does come with its own challenges. The good news is this option is available for 2022 and 2023 to encourage ACOs to begin the transition to all payer patient reporting across the entirety of the ACO, sooner than 2025. ACOs report the MIPS CQM/eCQM measures in the APM Performance Pathway (APP) measure set [with known targets] with the goal of achieving performance on one outcome measure at the 10th percentile of the performance benchmark and another quality performance score at or higher than the 30th percentile of the performance benchmark on at least 1 of the 5 remaining measures in the APP measure set. Known targets directly contribute to an ACOs ability to reach the quality performance standard to share in the savings they create and avoid maximum losses. Knowledge is key to helping organizations move the performance needle forward especially when the degree it needs to move is understood.
The final question is whether CMS will actually go through with the 2025 move to all payer quality reporting? We aren’t surprised that, after all the back-and-forth by CMS between the 2021 proposed rule and the release of the 2022 final rule, that ACOs may be skeptical that CMS may consider revising even the 2025 plan to retire the CMS Web Interface. After nearly ten years of quality reporting under various programs like the Physician Quality Reporting Initiative/System (PQRI/PQRS), Meaningful Use, VBPM and several others, I would caution against relying on CMS to flake out in 2025. CMS has effectively given ACO organizations four years to get their ducks in a row so data can be aggregated across multiple different billing and EHR systems and be submitted at the ACO level with a single submission file. History would suggest that ACOs should be ready for this change and that it may take the four years to make this transition. ACOs hoping to avoid losing out on shared savings and being responsible for maximum shared losses will begin the work now so they are ready for this major change in 2025
ReportingMD, Inc. has the expertise to get your ACO prepared so you can maximize your quality performance scoring to maintain the highest possible percent of shared savings your ACO works so hard to save for. Don’t lose out on your savings-ensure you’re prepared for the required transition to all payer reporting in 2025 so you can reward those providers and staff working so hard to keep your patients’ costs down and quality of care up!
About the Author, Molly Minehan, VP of Operations & Innovation, ReportingMD
Molly brings over 15 year of data research, analysis, and reporting, including the last 10 years with ReportingMD. Molly’s years of experience in Center for Medicare Services (CMS) pay-for-performance reporting on programs including the Merit-Based Incentive Payment System (MIPS), Accountable Care Organizations (ACOs), Comprehensive Primary Care (CPC+), and other Value-Based Care programs. Management of Client Services department and team, which supports and guides practices and clinicians on Value-Based Care reporting and outcomes management. Molly graduated from Wheaton College in Massachusetts.