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MIPS Blog

The APM Performance Pathway - Preparing Your ACO for Success

Posted on January 21, 2021
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In the 2021 Final Rule for the Quality Payment Program (QPP), the Centers for Medicare and Medicaid Services (CMS) introduced a new reporting framework for MIPS Alternative Payment Models (APMs) and Accountable Care Organizations (ACOs) called the APM Performance Pathway (APP).  CMS will also sunset the Web Interface as a collection and submission type in 2022.  In this article we highlight the implications for ACOs as they are required to report through the APP, including the new APP quality measure set and strategies for successful reporting.  

The APM Performance Pathway (APP)

CMS designed the APP to change how MIPS APM performance is reported and scored 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, the APP will be required for all Medicare Shared Savings Program (MSSP) ACOs beginning in 2021.  

The APP performance category weights and provisions are illustrated in the table below:

Performance CategoryPerformance Category WeightMeasures
Quality50%

Measure set consists of 6 measures.

CMS Web Interface
measure flexibilities for ACOs for the 2021 performance period only.* 

Promoting Interoperability30%Reported and scored at the individual or group level as required for the rest of MIPS.
Improvement Activities20%

Score is automatically assigned based on the requirements of participants’ MIPS APMs.

2021 - All APM participants reporting through the APP will earn of a score of 100%.

Cost0%Reweighted

*More information on 2021 reporting flexibilities can be found in this blog.
 

A Closer Look at Quality Reporting for ACOs

ACOs have historically reported Quality measures through the CMS Web Interface.  The CMS Web Interface will sunset as a collection and submission type in 2022, but CMS has extended its availability through the 2021 performance period.  In 2021 ACOs can report measures via the traditional Web Interface or the new APP Quality measure set (which includes 3 eCQMs/MIPS CQMs focused on diabetes, depression screening and hypertension).  ACOs can also report both options and CMS will choose the best score.  Beginning in 2022 ACOs will be required to report the 3 eCQMs/MIPS CQMs via a registry like MDinteractive or an EHR.  

ACOs will only need to report one set of quality metrics via the APP that will satisfy the quality reporting requirements under both the Shared Savings Program and MIPS.  All quality data reported via the APP will be used to calculate MSSP scores and used for purposes of calculating shared savings and shared losses. 

Quality Measure Set

The APP measure set will include the 3 self-reported Quality measures (eCQMs/MIPS CQMs), 2 measures calculated by CMS using administrative claims data and a patient experience measure.  ACOs will be required to report the APP measures outlined in the table below beginning in 2022.

APP Quality Measure Set
Measure  NumberMeasure TitleCollection TypeSubmitter Type
Quality ID#: 001Diabetes: Hemoglobin A1c (HbA1c) Poor ControleCQM/MIPS CQM/CMS Web InterfaceAPM Entity/ThirdParty Intermediary 
Quality ID#: 134Preventive Care and Screening: Screening for Depression and Follow-up PlaneCQM/MIPS CQM/CMS Web Interface*APM Entity/ThirdParty Intermediary 
Quality ID#:236Controlling High Blood PressureeCQM/MIPS CQM/CMS Web Interface*APM Entity/ThirdParty Intermediary
Quality ID#: 321CAHPS for MIPSCAHPS for MIPS SurveyThird-Party Intermediary
Quality ID#: 479 Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups Administrative ClaimsN/A
Quality ID#: 480Risk Standardized, AllCause Unplanned Admissions for Multiple Chronic Conditions for ACOsAdministrative ClaimsN/A


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 all 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 #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 would 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. 

MeasureCollection TypeDecile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10
Quality #1*MIPS CQM72.51-55.1655.17-41.9755.17-41.9741.98-32.5532.56-25.4725.48-19.1419.15-12.86<=
12.87
 
Quality #1*eCQM69.42-53.5953.6-
42.1
53.6-
42.1
42.11- 34.0534.06-28.3128.32-23.5523.56-19.09<=19.1
Quality #134MIPS CQM0.01-
14.75
14.76-37.4337.44-55.9255.93-71.7371.74-84.6884.69-95.5595.56-99.21>=
99.22
Quality #134eCQM0.01-
7.67
7.68- 14.6214.63-23.4823.49-33.9733.98-45.6345.64-59.8359.84-73.85>=
73.86
 
Quality #236MIPS CQM20-
29.99
30-
39.99
40-
40.99
50-
59.99
60-
69.99
70-
79.99
80-
89.99
>=90
Quality #236eCQM0.07-
51.68
51.69-57.0757.08-61.3261.33-64.7964.8-
68.44
68.45-72.0372.04-76.35>=
76.36

*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: 

  • Performance years 2021 and 2022: A quality performance score that is ≥ 30th percentile across all MIPS Quality performance category scores. 
  • Performance year 2023 and beyond: A quality performance score that is ≥40th percentile across all MIPS Quality performance category scores

Beginning January 1, 2022, for ACOs in the first performance year of their first agreement period under the Shared Savings Program, an ACO would meet the quality performance standard if it meets the MIPS data completeness and case minimum requirements on all 3 of the eCQM/MIPS CQM measures and fields the CAHPS for MIPS Survey via the APP.

ACO Reporting Success

CMS is providing a one-year transition period to give 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 on transitioning to a new measure set, new reporting mechanisms, and all-payer reporting. That’s why it’s critical to begin preparing for these changes now and to choose a partner that can offer strategies to help make this a smooth transition.

Key Considerations

  • Aggregating Data from Multiple Practices and EHR Systems. We understand that many ACOs face unique reporting challenges because they may need to combine data from multiple practices and EHR systems. MDinteractive has extensive experience with aggregating data from multiple EHR platforms and can accept various types of quality data files.  MDinteractive can aggregate data from multiple QRDA III files from different TINs into a single file that can be submitted at the APM entity level. We provide real-time performance reports of the aggregated data with benchmarking to optimize performance and shared savings.
  • Transitioning to a New Submission Method.  Next year ACOs will have to report the 3 eCQMs/MIPS CQMs via a registry like MDinteractive or an EHR. 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 year 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.   

Looking Forward

The new APP will be required for all MSSP ACOs beginning in 2021.  While they can postpone reporting the 3 eCQMs/MIPS CQMs until 2022, they should begin to identify a new data collection mechanism and modify operational workflows where needed.  Even if an ACO chooses to use the CMS Web Interface in 2021, it is important to start reviewing their performance on the 3 APP Quality measures now.  MDinteractive can help make this a smooth transition and set ACOs up for reporting success.  Contact us today to learn how MDinteractive can help your organization prepare for the changes ahead.  

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

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