Medicare Shared Savings Program: eCQM Reporting Transition Insights from CMS Proposed Rule

On July 10, 2024, the Centers for Medicare & Medicaid Services (CMS) released the proposed rule for the 2025 Medicare Physician Fee Schedule (PFS). The proposed rule includes several key changes affecting Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs), as CMS continues its shift towards digital quality measures (dQMs). With the CMS Web Interface concluding after the 2024 performance year, the proposed rule focuses on the future of quality reporting by aligning with the Universal Foundation of quality measures and extending electronic Clinical Quality Measure (eCQM) reporting incentives. This blog summarizes the proposed changes and examines their implications for ACOs in 2025 and beyond.

Current Quality Reporting Framework 

CMS implemented a multi-year transition from 2021 to 2024 for MSSP ACOs to move from reporting quality data through the CMS Web Interface to using eCQMs under the Alternative Payment Model (APM) Performance Pathway (APP). MSSP ACOs are required to report quality data via the APP to meet the quality performance standard used to determine shared savings and shared losses.

In 2024, these ACOs have the option to fulfill APP quality reporting requirements by either reporting the Web Interface quality measure set (10 measures) or the APP quality measure set (3 measures via eCQMs, MIPS CQMs, and/or Medicare CQMs collection types). The 2024 performance period marks the final year that MSSP ACOs can report via the CMS Group Practice Reporting Option (GPRO) Web Interface.

For 2024, the APP quality measure set includes three measures:

• CMS 122: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (Quality ID 001)
• CMS 2: Preventive Care and Screening: Screening for Depression and Follow-Up Plan (Quality ID 134)
• CMS 165: Controlling High Blood Pressure (Quality ID 236)

In addition to reporting the measures outlined above, ACOs must also administer the Consumer Assessment of Healthcare Providers Survey (CAHPS), and CMS will also calculate two measures using administrative claims data.

Proposed Changes to the APP Reporting Requirements 

Building on this transition, CMS intends to continue evolving its approach with the proposed rule, which would further advance Medicare’s overall value-based care strategy for measuring and encouraging improvements in care through the MSSP and the Quality Payment Program.

The APP Plus Quality Measure Set

The APP Plus quality measure set would be established to align with the Adult Universal Foundation measures. This new set would be mandatory for MSSP ACOs. Under the proposed approach, the APP Plus quality measure set will gradually expand to include eleven measures. This set will start with the six measures from the current APP quality measure set and will add five new measures from the Adult Universal Foundation measure set over the performance years 2025 to 2028. In 2025 the APP Plus quality measure set for MSSP ACOs would include a set of eight measures (five eCQMs/Medicare CQMs, two administrative claims measures, and the CAHPS for MIPS survey). 

CMS proposed the following timeline for adding the 5 Adult Universal Foundation quality measures to the APP Plus quality measure set:

eCQMs and Medicare CQMs - Only Reporting Options for MSSP ACOs

Starting in the performance year 2025, ACOs using the APP Plus quality measure set will have only two reporting options: eCQMs and Medicare CQMs. CMS proposes to remove the MIPS CQM collection type to focus ACOs on adopting the APP Plus measure set and promoting the use of eCQMs. 

Medicare CQMs are MIPS CQMs reported for an ACO’s eligible Medicare fee-for-service population instead of the ACO’s all-payer/all-patient population. Medicare CQMs would act as a transitional step toward prioritizing the adoption of eCQMs as CMS aims to fully transition to digital quality measurement in CMS quality reporting and value-based purchasing programs.

Flat Benchmarks for Medicare CQMs

Beginning in 2025, ACOs reporting Medicare CQMs would be scored using flat benchmarks for the measures’ first two performance periods in MIPS. A quality performance benchmark is
the performance rate an ACO must achieve to earn the corresponding quality points for each measure. Flat benchmarks assign a performance rate range to each decile. In flat benchmarks
for non-inverse measures, any performance rate at or above 90 percent would be in the top decile; any performance rate between 80 percent and 89.99 percent would be in the second highest decile, and so on. For inverse measures, this would be reversed—any performance rate at or below 10 percent would be in the top decile; any performance rate between 10.01 percent and 20 percent would be in the second highest decile, and so on.

The table below lists the  flat benchmarks for a non-inverse Medicare CQM in its first two performance periods in MIPS in performance year 2025 and subsequent years:

For example, if an ACO reports a non-inverse Medicare CQM in its first two performance periods in MIPS in performance year 2025 and earns a performance rate of 55.25 percent, then the ACO would score in the 6th decile on that measure.

eCQM Reporting Incentives

To encourage ACOs to transition more quickly to eCQMs and take advantage of digital data and interoperability, CMS proposes to extend the eCQM reporting incentive. The incentive will apply only to those ACOs that report all eCQMs in the APP Plus quality measure set and meet the data completeness requirements. This incentive will not be available to ACOs reporting a mix of eCQMs and Medicare CQMs or only Medicare CQMs.

For performance year 2025 and beyond, an ACO will qualify for maximum shared savings and avoid maximum shared losses by meeting all of the following criteria:

• Reporting all eCQMs in the APP Plus quality measure set for the performance year and meeting the data completeness requirements; 
• Achieving a quality performance score at or above the 10th percentile of the benchmark on at least one of the four outcome measures in the APP Plus set; and
• Achieving a quality performance score at or above the 40th percentile of the benchmark on at least one of the remaining measures in the APP Plus set.

Complex Organization Adjustment

CMS is proposing to add an adjustment to address the challenges ACOs face when reporting eCQMs. Specifically, the proposed rule would:

• Give one extra measure achievement point for each submitted eCQM submitted that meets data completeness and case minimum requirements.
• This adjustment would not exceed 10% of the total measure achievement points available in the quality performance category.

Merit-Based Incentive Payment System (MIPS)

CMS proposes minimal changes to MIPS for ACOs in 2025, with performance category weights remaining unchanged for those subject to MIPS. Additionally, CMS intends to maintain a 75-point performance threshold for the 2025 performance year, affecting payments in 2027.

Public Comment Period

This proposed rule is open for public comment, and stakeholders are encouraged to provide feedback to help shape the final regulations. The public comment period will close on
September 9, 2024. A final rule is expected to be released sometime in November.

ACOs MSSP ACOs eCQM reporting Medicare CQMs APM Performance Pathway