The Quality Payment Program (QPP) has allowed large organizations to use the CMS Web Interface reporting method to complete MIPS requirements since the program launched in 2017. This gave these organizations the option to report a sampling of 248 patients (selected by Medicare Part B claims) across all their practices. CMS will completely sunset the CMS Web Interface reporting option by 2025.
In 2025, all MSSP ACOs must report either eCQMs or CQMs for all patients, all payers, across all practices for 365 days of the year.
Figuring out data aggregation, de-duplication, and comprehensive performance review before 2025 is the key to your success. Below is a summary of your requirements and tips for getting started.
There are three reporting frameworks available in the Quality Payment Program, but MSSP ACOs can only submit to one, the APM Performance Pathway (APP) reporting framework.
Also read: A comparison of the 2023 requirements for all three reporting frameworks.
For the APP framework there are three categories, Quality, Promoting Interoperability, and Improvement Activities. Cost is weighted at 0%. This article will focus on the Quality category only. See article above for information on the other categories.
Collection types are the way you report the data to CMS. You can think of them like measures. There are six collection types in 2023.
NOTE: CMS has added a new collection type for 2024. Learn more about the Medicare CQM >>
Option 1 (<<your only option in 2025)
Option 2 (<<not available in 2025)
Option 3 (<<not available in 2025)
Quality Measures
Claims Measures
CAHPS for MIPS Survey measure
In 2023, for an MSSP ACO to get the maximum shared savings they must achieve a quality performance score that is greater than or equal a certain percentile of the benchmark and meet the Shared Savings Program Quality Performance Standard. CMS has implemented a sliding scale to give ACOs some percentage of the Shared Savings (not max) if they don’t meet the Quality Performance Standard but do achieve a quality performance score.
These are very low performance rates. You are likely achieving above these percentages for your CMS Web Interface measures. Here is an excel sheet that shows you the deciles for these measures. 10thpercentile means decile 1 in the sheet. 30th percentile means decile 3 in the sheet. Both Diabetes and Controlling High Blood Pressure are outcomes measures. If you achieve either of these scores below, you’d be eligible to share in saving.
NOTE: In 2024, this goes up to = > 40th percentile for CMS Web Interface measures. But even more importantly (!) this remains at = > 40th percentile in 2025 which means your eCQMs/CQMs must reach decile 4 by 2025.
One final thing to know about the Shared Savings portion. You will know individual measure performance benchmark score ranges (reference the excel sheet I gave you). You will not know the Quality Performance Standard threshold which is determined by looking at all MIPS Quality Performance Scores nationwide. CMS calculates that after the submission is done (March 2024).
There has been SO MUCH discussion on this topic. I once watched an ACO representative grill a CMS representative in a live panel discussion for no less than 20 mins on this topic. I think we all left even more confused. CMS attempted to make it clearer (which they are terrible at). So, here’s the best summary and documentation I can offer you.
An ACO must submit their entire “universe” of patients. None of your practices can be excluded based on populations. The data completeness threshold really would only be applicable in a MIPS CQM situation and even in that situation you still must have the entire universe of practices/patients and only achieve 70% completeness on the denominator patients.
Take a look at pages six and eight of the APP guidance document here.
It’s an unlikely scenario. But in some cases, an abstractor can't find the documentation that’s required by the measure. In this red scenario below an abstractor answers “no” to algorithm questions for more than 30% of cases.
ACOs must learn to juggle multiple, disparate EHRs and data collection methodologies. Developing a cohesive data aggregation system is going to be a major undertaking. Your senior leadership, quality management, and information technology teams need to start planning what that looks like for your ACO now.
The most important thing you can do right now is understand what your data landscape looks like. Here are a couple of questions you should know.
This information will help you to choose whether you want to submit eCQMs or MIPS CQMs. It will also inform you as to whether or not you have to set up conversations with any practices not able to provide your group with what you need.
This is completely dependent upon your organization set up. For most of our clients, we tell them to estimate a 6–8-month implementation time before you start to see any meaningful data.
Yes, it’s true. History has proven that CMS could change the rules and deadlines on us any minute, however, in the 2023 final rule CMS made it clear that they are still intending to sunset the CMS Web Interface Measures by 2025 for everyone.
It's in your best interest to start looking at your data through the all-patients, all-payers, all-practices lens now. It is the key to unlocking so many other patient care goals for you, including improving population health, reducing health care costs, and advancing health equity. For too long, the CMS Web Interface had made quality reporting a box that organizations had to check. It’s time now for organizations like yours to lead the charge to elevate the role of quality data in patient care. Together, we have the power to put quality data to good use.
At Medisolv, we offer so much more than quality software and start-to-finish submissions management. We’re the quality improvement partner committed to deciphering and anticipating CMS’s regulatory changes for you—so that you can keep your organization ahead of the curve.
Check out some of our additional resources now:
Medisolv Can HelpAlong with award-winning software, each client receives a dedicated Clinical Quality Advisor that helps you with your technical and clinical needs. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. Especially if you use an EHR vendor right now, you’ll notice a huge difference.
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