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On July 13, 2023, the Centers for Medicare & Medicaid Services (CMS) introduced a proposed rule for the 2024 Medicare Physician Fee Schedule (PFS). This proposal delineates changes to the Medicare Shared Savings Program with the aim of helping Accountable Care Organizations (ACOs) transition to a digital quality measurement approach and addressing concerns raised by ACOs and other stakeholders.
Starting in 2024, ACOs will have the option to report the three quality measures listed below on only their Medicare beneficiaries using Medicare CQMs, under the Alternative Payment Model Performance Pathway (APP):
- #1 Diabetes: Hemoglobin A1c (HbA1c) Poor Control
- #134 Preventive Care and Screening: Screening for Depression and Follow-up Plan
- #236 Controlling High Blood Pressure
In 2024, the rule allows ACOs to report quality data using the CMS Web Interface, eCQMs, MIPS CQMs, and/or Medicare CQMs collection types. However, the proposed rule indicates that the CMS Web Interface will no longer be available for ACO quality reporting in 2025, requiring ACOs to report quality data using eCQMs, MIPS CQMs, and/or Medicare CQMs.
ACOs may report the three Medicare CQMs, or a combination of eCQMs, MIPS CQMs, and Medicare CQMs, to meet the Shared Savings Program quality reporting requirements.
Medicare CQMs
A Medicare CQM is essentially a MIPS CQM that is reported solely on the ACO's Medicare fee-for-service beneficiaries, rather than its all-payer/all-patient population.
As is the case with eCQMs and MIPS CQMs, a qualified registry and other third-party intermediaries will be able to calculate and submit Medicare CQMs to CMS on behalf of an ACO.
To help ACOs improve the health of their populations and reduce healthcare costs, CMS will provide ACOs with a list of beneficiaries who are eligible for Medicare CQMs. This list will be updated annually at the beginning of the quality data submission period. The list will include the minimum data necessary to facilitate reporting of Medicare CQMs, such as beneficiary identifier, gender, date of birth and death (if applicable), chronic condition subgroup, and the NPIs of the top three frequented providers in the ACO. CMS also proposes to include health status information such as risk profile and chronic condition subgroup, to the extent that such data would aid ACOs in identifying patients that meet the denominator criteria for the Medicare CQM Specifications.
However, it will not be a complete list of beneficiaries who should be included in an ACO's Medicare CQMs reporting, because we will not have full run-out on performance year claims data at that time. ACOs would have to ensure that all beneficiaries who meet the applicable Medicare CQM specification, and also meet the definition of a beneficiary eligible for Medicare CQMs are included in the ACO’s eligible population/denominator for reporting each Medicare CQM.
The proposed rule defines a beneficiary eligible for Medicare CQMs as either:
- A Medicare fee-for-service beneficiary who meets the criteria for being assigned to an ACO and who had at least one claim with a date of service during the measurement period from an ACO professional who is a primary care physician, a specialist with one of the designated specialties (Cardiology, Osteopathic manipulative medicine, Neurology, Obstetrics/gynecology, Sports medicine, Physical medicine and rehabilitation, Psychiatry, Geriatric psychiatry, Pulmonary disease, Nephrology, Endocrinology, Addiction medicine, Hematology, Hematology/oncology, Preventive medicine, Neuropsychiatry, Medical oncology or Gynecology/oncology), a multispecialty group practice or a PA, NP, or CNS.
- A Medicare fee-for-service beneficiary who is assigned to an ACO because the beneficiary designated an ACO professional participating in an ACO as responsible for coordinating their overall care.
If an ACO wants to report Medicare CQMs in a given year, they will need to aggregate patient data for all beneficiaries who are eligible for Medicare CQMs. They will then need to match this data with each Medicare CQM Specification to identify the eligible population for each measure. The ACO's submission must account for 100% of the eligible and matched patient population across all ACO participants.
The intent of the Medicare CQMs is to act as a transitional collection type, helping ACOs build the infrastructure, skills, knowledge, and expertise necessary to report all-payer/all-patient MIPS CQMs and eCQMs.
CMS believes that Medicare CQMs would alleviate the concerns of ACOs with a higher proportion of specialty practices. They fear that the broader all-payer/all-patient eligible population might include beneficiaries who lack a primary care relationship with the ACO. ACOs would be able to utilize Medicare claims data to aid in identifying their eligible population and validating their patient matching and deduplication efforts by adopting Medicare CQMs as a new collection type. However, the long-term goal of CMS remains to support ACOs in the adoption of all-payer/all-patient measures.
CMS may stipulate higher standards, introduce new measures, or phase out the Medicare CQM collection type in future rulemaking.
The eCQM/MIPS CQM reporting incentive will not apply to Medicare CQMs
CMS is not including Medicare CQMs in the eCQM/MIPS CQM reporting incentive for the performance year 2024. ACOs reporting Medicare CQMs need to achieve a health equity adjusted quality performance score that is equivalent to or higher than the 40th percentile across all MIPS Quality performance category scores.
ACOs reporting eCQMs or MIPS CQMs merely need to achieve a quality performance score equivalent to or higher than the 10th percentile of the performance benchmark on at least one of the four outcome measures in the APP measure set. Additionally, they need to achieve a quality performance score equivalent to or higher than the 40th percentile of the performance benchmark on at least one of the remaining five measures in the APP measure set.
The eCQM/MIPS CQM reporting incentive aims to encourage ACOs to report all-payer/all-patient eCQMs/MIPS CQMs.
Benchmarking Policy for Medicare CQMs
CMS intends to formulate benchmarks for rating ACOs on the Medicare CQMs under MIPS, in line with the existing MIPS benchmarking policies. Given the lack of historical Medicare CQM data, CMS proposes to utilize performance period benchmarks for evaluating Medicare CQMs for the performance years 2024 and 2025. As quality performance data starts being submitted through Medicare CQM and baseline period data becomes accessible to establish historical benchmarks, CMS proposes, for performance year 2026 and subsequent years, to transition to the use of historical benchmarks for Medicare CQMs. This transition will be made once baseline period data is sufficient to establish historical benchmarks, and it will be done in a way that aligns with the MIPS benchmarking policies.
Health Equity Adjustment Will Apply to Medicare CQMs
In line with the objective of aiding ACOs in their shift to eCQMs/MIPS CQMs, CMS proposes that ACOs reporting Medicare CQMs should be eligible for the health equity adjustment to their quality performance category score when determining shared savings payments. Specifically, CMS suggests that, starting from performance years 2024 and the years following, a health equity adjusted quality performance score should be calculated for an ACO that reports the three Medicare CQMs, or a mix of eCQMs/MIPS CQMs/Medicare CQMs, in the APP measure set, fulfills the data completeness requirement for each measure, and conducts the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey. The application of the health equity adjustment to an ACO’s quality performance category score when reporting Medicare CQMs would acknowledge ACOs that serve underserved populations and deliver high-quality care.
Next Steps
MDinteractive is a CMS Qualified Registry and is certified by the Office of the National Coordinator for Health Information Technology (ONC) to generate eCQMs. MDinteractive can process and report eCQMs, MIPS CQMs, and the newly proposed Medicare CQMs.
ACOs have less than a year and a half to prepare for eCQM, MIPS CQM, or Medicare CQM reporting before it becomes mandatory in 2025. MDinteractive offers cost-effective solutions for aggregating data from multiple sources (EHR, claims, etc.), multiple data types (QRDA, FHIR, 837P billing files, etc.), data validation, and performance tracking. Gaining this experience now is the best way to ensure future reporting success. Schedule a meeting to learn more about how MDinteractive can help your ACO successfully navigate eCQM and CQM reporting.
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