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Digital Quality Measures, Clarification on 2015 CEHRT Requirements, and more!

In this week’s edition of Ask Dr. Mingle, Dr. Dan Mingle further explains the state of Digital Quality Measures after the 2023 Final Rule. He also shares insight into 2015 CEHRT requirements for MSSP ACOs and provides some perspective on positive adjustments for the 2022 Performance Year.

Click play to listen to this week’s episode now:

Question One: Digital Quality Measures

Aireen asks: You’ve mentioned that Digital Reporting was not discussed in the 2023 Final Rule. Are you referring to eCQMs or MIPS CQMs being required in Performance Year 2025 to replace the Web Interface? Can you please explain this a little bit more?

I was not referring to replacing the Web Interface with eCQMS and MIPS CQMs.

You are not alone in confusing these terms. The relationship between eCQMs, MIPS CQMs, the APM Performance Pathway (APP), and Digital Quality Measures needs to be more widely understood. Even Medicare is distributing confusing and conflicting messaging about the subject.

In 2021, in rulemaking for the 2022 performance year, Medicare introduced the concept of Digital Quality Measures (dQMs), proposed the audacious goal that quality reporting for the Quality Payment Program would be entirely digital by 2025, and issued a request for input.

It seemed obvious then that Digital Quality Measures needed to be more adequately defined – they were unlikely to be desirable and unachievable to any reasonable specification in such a short time frame.

My reason for bringing it up is that there is no good evidence that this will change our lives by 2025. Two things have happened since Medicare introduced the topic in 2021 that support that conclusion:

  • In March of 2022, Medicare issued a Digital Quality Measurement Strategic Roadmap. You can access the strategic roadmap and other collateral here: Digital Quality Measures | eCQI Resource Center (
    • It’s a good document. It describes the current situation well, presents a laudable vision for a more functional future, and lays out a reasonable and rational set of work that could credibly get us there. But nowhere in the strategic roadmap is there mention of a date for complete conversion to a digital measurement system.
  • And, in this Final Rule for the 2023 Performance Year, there are only two mentions of the Digital Quality Measurement Strategy and no mention of an implementation date.
    • One mention is an acknowledgment that it was previously the subject of a request for information.
    • The other mention is in a routine footnote in each published measure specification.

We’ve seen evidence that ACOs are building IT strategy around the expectation that eCQMs will shortly be the only way to meet Medicare APP quality reporting requirements.

Even the NAACOS Digital Quality Measurement Task Force recommends against using MIPS CQMs, arguing that such a system will have to be rebuilt when Medicare requires eCQMs only.

This argument involves mistaken assumptions that could lead to self-destructive, excessively fragile, and costly strategies.

It is not a reasonable assumption that Medicare will successfully create a fully digital measurement system within a short period. The legislation does not require it. And it has yet to be reflected in the rules except as an RFI.

Additionally, don’t assume that your MIPS CQM vendor won’t still be the best source of your eCQM measure analytics and submission.

EHRs are not good at quality analytics and reporting. It does not fit their business model. It’s an enormous ask to expect them to report out of multiple platforms or show the necessary flexibility in measure choices and data sources.

In contrast, it’s a small step for Qualified Registries to restrict their analytics and reporting to digital data sources. And it is a comparatively small step to acquire eCQM certification instead of, or in addition to, annual CMS qualification as a registry.

Question Two: Perspective on MIPS Study

Wally asks: Could you speak to the recent study published in the Journal of the American Medical Association that states “Study Calls Medicare Pay-for-Performance Program Results Into Question — MIPS doesn’t consistently correlate with process, outcome measure performance in primary care?”

This article with lead author Amelia Bond, Ph.D., of the Department of Population Health Sciences at Weill Cornell Medical College, reports on a study of over 80k primary care providers. In this study, MIPS scores did not consistently correlate to the research group’s independent assay of quality of care. Scores were reported to correlate with the proportion of medically complex and socially vulnerable patients in the practice, with high proportions leading to lower scores.

Considering the process and its limitations, it makes sense. It’s a simple set of measurements in a complex system. It makes sense that it more effectively measures our ability to generate metrics than our actual quality of care.

This realization should not prompt us to dump the system. Instead, it should illustrate the need to engage, perform studies of this type, and continually provide feedback to the custodians of the programs.

J.E. Deming and others warn us against incentive systems – they are prone to perverse rewards and undesirable outcomes.

That doesn’t mean we should end the program. There is no service, and there is no life without incentives and disincentives. We must continually monitor and adjust the incentive system to give us what we want.

This article contributes to an awareness that the MIPS system, as a whole, functions as an incentive/disincentive.

We imagine that it measures a high-value outcome of our health care system. But, if this study provides useful data, it is to see the MIPS system as more of a process measure than an outcome measure. Today it shows how effective we are at documenting our care and recovering information about it to report to stakeholders.

MIPS currently requires each participant to choose six measures from a menu of nearly two hundred to reflect the quality of our care.

My friend, Brian Alper, who founded DynaMed, tells me he and his team of reviewers distilled over 30,000 evidence-based rules from the medical literature. A more accurate quality measure is the efficiency and effectiveness at which we deliver all 30,000 of those interventions to patients where indicated. And maximal delivery of each intervention is never an accurate measure of quality. When measuring efficiency and effectiveness, you must consider patient limitations, beliefs, and priorities.

If we wish to build a high-value healthcare system, we must systematize that care. The technological foundation of our care systems needs to be steadily improved and put to work on making high-quality, affordable care accessible to all.

MIPS, and indeed the entire Quality Payment Program, is about pushing us in the right direction. It’s about incentivizing us to systematize our care. The QPP has to evolve. At the point where it stops changing, it stops supporting high-value care.

We need studies such as this one to illuminate the system failures and stimulate the next evolution.

Question Three: Positive Adjustments for 2022

Brad asks: Are there any perspectives on what the positive adjustment is projected to be for Performance Year 2022 (paid in 2024)?

Submissions for 2022 are due by the end of March 2023. Then Medicare will process the submissions and determine scores and adjustments.

There may be some indication released in the proposed rule in July 2023. Results will likely be published in August, though they will still be subject to focused review.

The 2022 performance year is the last year of the Exceptional Performance Bonus, which is good for a nearly 2% positive adjustment. Currently, COVID hardship exception applications are encouraged but have yet to be automatic. That dynamic will tend to reduce the maximum positive adjustment. My guess is that it will be in the 2 to 2.5% range.

Question Four: Clarifying 2015 CEHRT Requirements

Crystal asks: Is my understanding correct: The Medicare Shared Savings Program (MSSP) can still have practices that are not on 2015 CEHRT but MIPS must have a 2015 CEHRT?

It does seem unfair and inconsistent. But there is a logic and a balance to it.

In MIPS, it is not a solid and unbendable requirement to have 2015 CEHRT:

  • Any practice can choose not to implement EHR or use a platform that is not certified.
    • The “price” of that choice for those practices is a zero score on MIPS Promoting Interoperability.
      • Detrimental? Yes. But it could be a sound business decision.
  • In addition, roughly 1/3 of our healthcare providers are in small practices.
    • These practices get automatic forgiveness of the Promoting Interoperability category score.

In the complex system that is each of our community healthcare systems, most have members without 2015 Certified EHRs. Hence, the lenience in the MSSP rules. MSSP requires 75% of its participants to have certified EHR; failure can result in expulsion from the program.

MSSP can be an advanced APM or a MIPS APM, depending on the details of the contract, specifically the degree of risk.

  • For the advanced APM groups, the 75% threshold is the only compliance demanded for the use of CEHRT.
  • The MIPS APM groups have to live up to the 75% contractual requirement and are subject individually to the MIPS Promoting Interoperability category scoring.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, Primary Care First, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

Want to learn more about the APM Performance Pathway (APP)?

As the Web Interface sunsets, ACOs must prepare to transition into the APM Performance Pathway (APP) reporting method by Performance Year 2025. For many ACOs, this task is daunting - with data challenges, technical hurdles, and a completely new reporting workflow. To help with this, we've created the APM Performance Pathway Checklist - a two-page resource to assist your organization in understanding and preparing for this challenge.

Access the Checklist
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