The APM Performance Pathway - Preparing Your ACO for Success

The Centers for Medicare and Medicaid Services (CMS) will delay the requirement that Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) begin reporting all-payer Quality data through the new APM Performance Pathway (APP). ACOs will have the option to continue submitting data via the CMS Web Interface through the 2024 performance year. ACOs will have to report all three APP Quality measures (CQMs or eCQMs) beginning in 2025. In this article, we highlight the implications for ACOs, including the new APP quality measure set and strategies for successful reporting in future years.  

The APM Performance Pathway (APP)

In the 2021 Final Rule for the Quality Payment Program (QPP), CMS introduced a new reporting process for MIPS Alternative Payment Models (APMs) and ACOs called the APM Performance Pathway (APP). The new reporting program will eventually replace the CMS Web Interface.  

CMS designed the APP to change how MIPS APM performance is reported and scored, to align with the new MIPS Values Pathway, and to encourage APM participation. The APP will provide uniform MIPS reporting requirements with a single, fixed set of measures for each performance category. Clinicians participating in a MIPS APM can choose to report MIPS through the APP or through the traditional MIPS program. However, CMS will transition to mandatory reporting of APP quality measures by MSSP ACOs beginning in 2025.  

The APP performance category weights and provisions will differ from the traditional MIPS program as illustrated in the table below:

A Closer Look at Quality Reporting for ACOs

ACOs have historically reported 10 Quality measures through the CMS Web Interface. CMS will sunset the Web Interface after the 2024 performance year and require ACOs to report the three APP eCQMs/MIPS CQMs (focused on diabetes, depression screening, and hypertension) via a registry like MDinteractive or an EHR.  

CMS has established a longer transition period to give ACOs more time to prepare for the changes. ACOs can choose to continue reporting the 10 quality measures through the Web Interface for the 2021-2024 performance years. ACOs will then be required to report all three eCQMs/MIPS CQMs starting in 2025.   

Quality Measure Set

The APP measure set will include the three self-reported Quality measures (eCQMs/MIPS CQMs), two measures calculated by CMS using administrative claims data and a patient experience measure.  

The Quality measures included in the APP measure set focus on the management of chronic health conditions that have a high prevalence among Medicare beneficiaries and also the general population. CMS will require that the measures be reported for at least 70% of eligible patients regardless of payer type (both Medicare and non-Medicare patients) to assess the overall quality of care furnished by the ACO.  A description of each of the Clinical Quality Measures (CQMs) can be found below:

• Quality ID #1 (NQF 0059): Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%). This measure is reported on patients 18-75 years of age with diabetes whose most recent hemoglobin A1c level (performed during the measurement period) was greater than 9.0%. It is submitted a minimum of once per performance period.  Note that this is an “inverse” measure, meaning a lower calculated performance rate indicates better clinical care or control.  The “Performance Not Met” numerator option for this measure (patients with A1c of less than 9%) will produce a performance rate that trends closer to 0% as quality increases. 

• Quality ID #134 (NQF 0418): Preventive Care and Screening: Screening for Depression and Follow-Up Plan. This measure is reported on patients aged 12 years and older who were screened for depression on the date of the encounter or 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the eligible encounter.   This measure is submitted a minimum of once per measurement period.

• Quality ID #236 (NQF 0018): Controlling High Blood Pressure. This measure is reported on patients 18 - 85 years of age who had a diagnosis of hypertension overlapping the measurement period and whose most recent blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period.  This measure is submitted a minimum of once per performance period for patients with hypertension seen during the performance period.  Note that only blood pressure readings performed by a clinician or a remote monitoring device are acceptable for numerator compliance with this measure. 

Quality Measure Benchmarks

Under the APP, the quality performance score will be calculated for ACOs based on the same MIPS benchmarks that are used for other non-ACO individual and group reporters. Each of the Quality measures will be assessed against its benchmark to determine how many points the measure earns. Benchmarks will be specific to the collection type under the APP: MIPS Clinical Quality Measures (MIPS CQMs)* vs. Electronic Clinical Quality Measures (eCQMs) and are established using historical data based on actual performance data that was submitted to the QPP.  

ACOs will receive a score of between 3 to 10 points for each measure that meets the data completeness and case minimum requirements, which would be determined by comparing measure performance to the established benchmarks. Each benchmark is presented in terms of deciles. Points will be awarded within each decile (see table below). 

It is important to review the benchmarks for each measure based on the submission types as this will impact an ACO's scores. 

*Since measure #1 is an inverse measure where a higher performance is seen by a lower number on the performance score, the scores are reversed in the benchmark deciles.

Quality Performance Standard

CMS will gradually phase in an increase in the level of quality performance required for all ACOs to meet the Shared Savings Program quality performance standard. CMS has established the following performance standards based on reporting measures through the CMS Web Interface or the APP measures:

• 2022 to 2023 - ACOs will meet the quality performance standard used to determine shared savings and losses if the ACO:
  • Achieves a quality performance score equal to or higher than the 30th percentile across all MIPS quality performance category scores, excluding entities/providers eligible for facility-based scoring; or 
  • Reports the three eCQM/MIPS CQM measures (meeting data completeness and case minimum requirements) and achieves a quality performance score equal 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 and achieves a quality performance score equal to or higher than the 30th percentile of the performance benchmark on at least one of the remaining five measures in the APP measure set. 
• 2024 and subsequent performance years:
  • An ACO will meet the quality performance standard used to determine shared savings and losses if the ACO achieves a quality performance score equivalent to or higher than the 40th percentile across all MIPS quality performance category scores, excluding entities/providers eligible for facility-based scoring. 

ACO Reporting Success

CMS is giving ACOs additional time to set up their systems and prepare clinicians to become familiar with the new quality reporting requirements before the CMS Web Interface is removed as a submission option. We understand ACOs may have concerns about transitioning to a new measure set, new reporting mechanisms, and all-payer reporting. That’s why it’s critical to begin preparing now and choose a partner that can offer strategies to help make this a smooth transition.

Key Considerations

• Transitioning to a New Submission Method. ACOs will have to report all three eCQMs/MIPS CQMs beginning in 2025. MDinteractive has over 20 years of quality reporting experience working with healthcare providers of all sizes and in all practice settings, and we have been a Qualified CMS registry since 2010. Quality reporting is our focus, so we are familiar with the CQMs ACOs will have to report. We understand their measure specifications, how to identify eligible patients to report and what is required for measure compliance. MDinteractive simplifies the reporting process for ACOs and provides the tools and resources they need to optimize shared savings.
• Preparing to Collect All Payer Data. CMS will require ACOs to report the quality measures for all patients, regardless of payer type. This is a significant change from reporting on only a sampling of Medicare patients under the CMS Web Interface. Fortunately, ACOs will have a transition period to implement appropriate infrastructure changes to collect and report all-payer data. It will be important to closely monitor performance since ACOs will be evaluated on the quality of care furnished to all patients they serve. MDinteractive’s robust software tools will help ACOs plan, track, and optimize their quality reporting and performance and can accommodate data at the ACO level, by participating TIN, or at the individual clinician level.
• Reporting eCQM vs MIPS CQMs. Successfully reporting Quality will require planning to determine if reporting eCQMs or MIPS CQMs will yield higher performance scores. For example, if an ACO has been tracking a measure, such as depression screening, on an EHR field that is not the standard field used by the eCQM, then the ACO performance on that measure could look artificially low. A registry can calculate the performance based on the way the ACO collected the data as long as it meets the CQM specifications. Additionally, registries can accept data from patient chart reviews even if the clinical data has not been entered into the standard EHR fields. This flexibility can alleviate some ACO concerns over adapting and modifying their EHRs to comply with the eCQM specifications.  
• Managing Data from Multiple EHR Systems. We understand that many ACOs face unique reporting challenges because they use multiple EHR systems. MDinteractive has extensive experience with aggregating data from multiple EHR platforms and can accept various types of quality data files. We provide real-time performance reports of the aggregated data with benchmarking to optimize performance and shared savings.

Looking Forward

CMS has established a multi-year transition period to require all MSSP ACOs to report the new APP measure set. While ACOs won't be mandated to report the three APP Quality measures until 2025, there is a significant amount of planning needed to prepare for these changes.  ACOs should begin identifying a new data collection mechanism, modifying operational workflows where needed, and reviewing their performance on the Quality measures. MDinteractive can help make this a smooth transition and set ACOs up for reporting success. Schedule a meeting to learn more how MDinteractive can help your ACO successfully navigate eCQM and CQM reporting.

ACO Reporting APM Performance Pathway Measure #1 Measure #134 Measure #236