In this episode, Dr. Dan Mingle shares insight into eCQM reporting, explains current quality measure weighting for MSSP ACOs, and provides helpful context for what the 2023 COVID EUC Hardship Exception will mean for MIPS participants this year.

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Question One: ACO Pay-For-Reporting

Turner asks: “For an ACO’s first performance year, are you eligible for shared savings as a result of just reporting? I’m having a hard time keeping up with the most current versions of the CMS technical guidance and I see at one point that was the case.”

For an MSSP ACO in its first year ever, reporting is Pay-for-Reporting. Just submitting the report will earn you the maximum shared savings.

But that is not the whole story:

• Any MSSP in its first year is likely to be a MIPS APM.
• The APP quality submission will also determine the MIPS adjustment.
• For the MSSP share of savings, quality reporting is Pay-for-Reporting.
• But, the quality score is Pay-for-Performance in calculating the applicable MIPS adjustment for your MIPS-susceptible ACO participants.

Question Two: MSSP ACO Quality Measure Weighting

Turner also asks: “For ACOs, what is the current weighting for the measures vis-à-vis the administrative claims and experience of care results?”

Reminder: All MSSPs are now subject to APM Performance Pathway (APP) scoring. There are three options for the quality portion of the APP score:

• Web Interface
• eCQMs
• MIPS CQMs.

No matter the method you choose to submit, CAHPS is a single composite score, and both of the two administrative claims measures are weighted equally with each of the submitted measures for your final quality score.

In the case of eCQM and MIPS CQM submissions:

• There are six quality measures that each have a potential of 10 quality points.
• Participants will receive a score between 1 and 10 for each of the three submitted measures, two administrative claims measures, and a composite score for CAHPS (Experience of Care).
• The final score is the total score achieved divided by the 60-point potential.
• That, in turn, is multiplied by the total possible quality points in the APP MIPS Score.
• Quality usually counts for 50% of the APP MIPS Score.
  • It’s 75% if your ACO qualifies for and takes advantage of reweighting of the Promoting Interoperability score.

In the case of Web Interface submissions:

• Eight of the ten measures are scored in the Web Interface, accounting for 80 potential points plus 10 points each for the same two administrative claims measures and the composite CAHPS score.
• The final score is the total score achieved divided by the 110-point potential.

So the two administrative claims measures and the CAHPS experience of care composite are weighted:

• 30/110 points in a Web Interface submission
• 30/60 points in an eCQM/MIPS CQM submission

Question Three: eCQM Reporting

Emily asks: “Do you have resources available to prepare for eCQM reporting?”

I’ll begin my answer to this question by explaining that I don’t recommend eCQM reporting. Mingle Health has always maintained qualification by CMS as a Registry.

And for a time, we simultaneously maintained certification through ONC as an eCQM vendor. We dropped the eCQM reporting vendor certification because it added cost and effort to our products and services without adding value for our clients.

Specifically:

• Certification is a process measure applied to the process of quality reporting.
  • It shows that a vendor can understand specifications, standard data, and terminology.
  • And it shows that a vendor can generate accurate analytics with an idealized data set.
• In contrast, qualification by CMS is more of an outcome measure applied to the quality reporting process.
  • Registries are requalified annually in a process confirmed by an audit of the registry’s output.
    • Produce inaccurate analytics? Lose your qualification.

Production of eCQMs is rigid and uncompromising. eCQM reporting is exclusive, restricting the vendor to a standardized data flow, standard terminology, and a fully certified pathway from the patient to the data display.

But we find that real-world data is just more confusing and complex than is tested in the eCQM reporting certification process.

The registry processes that produce MIPS CQMs are, in contrast, inclusive. Registries can use all of the data sources that eCQM vendors can use, but all other data sources are also available.

As a registry, we are restricted only by the verifiable accuracy of our output.

eCQM quality benchmarks are often more favorable than MIPS CQM benchmarks:

• Typical scores are lower, on average, for eCQM submitters than for registry submitters.
• Scores are lower because they tend to miss more documentation elements.
• If clinician users don’t adhere rigidly to proscribed documentation standards, eCQM reporting processes can fail to identify the quality action.

In contrast, registries can expand the query to additional fields, search terms, and data sources to serve your clinicians where and how they document.

Our website has abundant resources to help prepare for and succeed with MIPS or APP Quality Reporting:

• MIPS CQMs, eCQMs, and Digital Quality Measurement: What do you need to know?
• How ACOs Can Satisfy APP Quality Reporting Requirements and How to Be FHIR Ready
• A Primer on ACO Participation, Optimizing with MIPS CQMs, and Data Completeness Examples
• Common eCQM Challenges, Focusing on ACO Quality Scores, and more!
• APM Performance Pathway (APP) Transition Checklist

Question Four: Clarifying MIPS for ACO Participants

Janet asks: “I am still uncertain what my MIPS-susceptible ACO participants need to do for MIPS reporting. Can you clarify this a little more?”

I’ll explain the four MIPS categories and what MIPS-susceptible ACO participants need to do for each category below.

Two MIPS categories require submission: Quality and Promoting Interoperability (PI).

Quality:

• Counts for 50% of the total MIPS Score.
• Medicare will repurpose your ACO’s APP quality submission to count toward MIPS.
  • If the ACO makes an APP quality submission, everyone who needs a MIPS quality score is assigned the ACO’s APP quality score for MIPS.
• The APP quality score represents average performance across all ACO participants.
  • So half of your participants would get a higher score on their own. Half would get a lower score on their own.
  • Your top performers might consider making a separate MIPS quality submission, either as an individual or as a TIN group practice.
• Medicare will grant the highest available score to any participant.
  • If they get a higher score from their individual or TIN group submission, they may get a higher MIPS adjustment.

Promoting Interoperability (PI):

• Counts for 30% of the total MIPS score.
• Each of your MIPS-susceptible participants will need a Promoting Interoperability submission to earn any of the 30 points toward the total score.
• Medicare offers exclusions for multiple reasons, like being a Small Practice or a Hospital-Based Practice.
• Otherwise, a submission can be made by:
  • Individual PI submission
  • TIN practice group submission
  • And starting in 2023, the APM entity can make one submission for the whole APM participating provider group.
• The way Promoting Interoperability scoring works, you’ll likely get the best score from the largest possible grouping of your providers.

And two MIPS categories require no submission: Cost and Improvement Activities (IA).

Cost:

• Cost does not contribute to the MIPS score for APM participants.
• Medicare calculates the Cost measures from Administrative claims – so no MIPS participant will ever submit anything for the Cost category.
• Cost is not scored for any APM participant.
• Cost does not contribute to the total MIPS score for MIPS APMs.

Improvement Activities (IA):

• Counts for 20% of the total MIPS score.
• No submission is needed for Improvement activities for APM participants. Medicare knows who you are and automatically assigns the scores.
• By legislation, APM participation always counts for at least 50% of the total possible IA score.
• Medicare assigns additional IA points if the APM design warrants it.
• So far, all APMs are good for full credit for Improvement Activity points.

Question Five: 2023 COVID EUC

Will asks: “I heard that CMS has declared again that there is a COVID EUC Hardship Exception available again for the 2023 Performance Year. Does that mean we don’t have to submit anything for  MIPS for 2023?”

Before addressing 2023, let me point out that Medicare is still accepting applications for COVID Hardship exceptions for 2022 until March 3, 2022.

Concerning 2023, the answer is “Maybe.”

Consider your options carefully before you skip your 2023 submission. Medicare is not granting any special consideration for COVID for 2023. They simply state that you can always apply for a hardship exception if you believe one exists for you for any reason, including COVID.

Regarding this new announcement: I first observe that it is not an automatic exception, as it has been in the first three COVID-affected submission seasons. In those years, if you did not submit, Medicare applied an automatic exception, and non-submitting providers were not subject to any adjustments.

So far, for the 2022 and 2023 performance years, you only get an exception if you apply for one.

We are late enough in the submission season for 2022 data that we are unlikely to see an automatic exception applied to 2022. I don’t think we will see one for 2023 unless there is a new variant or a new infectious agent that is significantly more infectious and/or fatal than we are now seeing.

Second, observing that COVID still affects all healthcare practices, and the exception is not automatic, expect it to require more than just the existence of COVID to warrant an exception. Your application should reflect how COVID is in the way of your participation:

• Did key clinicians or support staff suffer prolonged infection-related complications?
• Was your community or practice overwhelmed with COVID or complications?
• Did you use practice resources to upgrade your infection control infrastructure?

Third, on the surface, it’s a meaningless reminder. It should now be obvious to everyone that COVID is here to stay.

And hardship exception applications have always been available to Quality Payment Program participants. We should expect always to be able to apply for an exception from MIPS based on COVID-related hardships.

I don’t expect Medicare ever to say, “There will be no more hardship exceptions granted for COVID.”

Fourth, by choosing to remind us, Medicare is encouraging us to use the hardship exception. And by encouraging it, CMS implies an intent to be lenient when approving applications. Because Medicare issued a reminder, I expect more practices to apply for hardship exceptions and a high level of approval.

Finally, a warning:

• Though it’s reasonable to expect leniency, we won’t know how lenient they will be until Medicare starts accepting and acting on applications.
• And the degree of strictness or leniency we experience early in the season may be different late in the season as the political and infectious environments evolve.
• Whatever you experienced last year may not be your experience this year. Whatever you experience this year may not be the experience next year.

Apply for an exception if you need it. Support your application with concrete and credible observations. Don’t assume acceptance until it is granted.

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:

• You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.
• On LinkedIn, leave your questions in a comment on any of our posts.
• And you can reach out directly by sending an email to hello@minglehealth.com.