In this episode of Ask Dr. Mingle, Dr. Dan Mingle answers listener questions about benchmarks for APP measures, explains the confusion around MIPS CQMs for ACOs, and shares his insight on additional ACO-related questions.

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Question One: Benchmarks for APP Measures

Jason observes: “I’ve heard you say that, for APP reporting, the three APP measures have the same benchmarks whether they are submitted as eCQMs or MIPS CQMs. That’s not how I am reading the benchmarks.”

Jason, you are absolutely correct. My apologies for misleading you.

There has been some convergence and divergence of benchmarks over the last few years, but for 2023, the eCQM and MIPS CQM benchmarks are different for all three submittable APP measures.

And as a quick review:

• We are discussing the APM Performance Pathway (APP), the new quality standard for MSSP ACOs.
• There are six measures for the APP:
  • Two administrative claims measures
  • The CAHPS experience of care survey (treated as one composite measure)
  • And three measures submittable by eCQM or MIPS CQM mechanisms
  • In addition, for years 2021 through 2024, MSSP ACOs can continue to abstract charts and submit performance data for the ten measures of the Web Interface.
  • After reporting for the 2024 Performance Year, the Web Interface will be sunset, and all MSSP ACOs will need to use eCQMs or MIPS CQMs for the APM Performance Pathway.
  • In the overlap years, Medicare applies a favorable quality standard to MSSPs switching early to the APP using MIPS CQMs or eCQMs.
    • A lower score earns full sharing of savings or reduced sharing of losses.

With the background covered, I’ll explain the benchmarks.

The three current APP CQM measures are:

• #1 HbA1c in diabetics
• #134 Depression Screening
• #236 Control of Hypertension

Medicare calculates benchmarks every year for each measure from the data submitted, grouping submitted performance into ten true deciles of performance, then mathematically adding three decimal places of discrimination.

But this year’s data is graded against last year’s benchmark calculations. It’s not a real decile or percentile ranking, but it’s close.

Medicare calculates separate benchmarks for each submission mechanism for each applicable measure. So, there will be different benchmarks for Web Interface, Claims, Administrative Claims, MIPS CQMs, and eCQMs.

For 2023, for each of the three APP measures, a raw performance score submitted as an eCQM would get a higher translated ranked score than the same performance score as a MIPS CQM.

That means if you could count on the same performance score from either mechanism, it would always be preferable to submit the eCQM. You’d get a higher comparative decile ranking.

But of course, all measurements by all mechanisms are faulty. That’s a subject nicely reviewed in a recent JAMA article.

Measurement not only reflects actual differences in performance but also reflects differences in the effectiveness of both documentation and recovery of data.

And eCQMs are routinely less accurate than MIPS CQMs. eCQMs underperform compared to MIPS CQMs on two issues:

1. Certification: if any step in your data flow passes through an uncertified process, the eCQM submission is invalid and may be rejected.

• eCQM vendors, usually EHRs, are “Certified” by ONC.
  • Certification grades the ability of the vendor to read and write QRDA1 and QRDA3 files. It’s a process measure of measurement solutions.
• MIPS CQM vendors are “Qualified” by CMS.
  • Qualification is an annual review of capabilities and includes a periodic audit of results. More of an outcomes measure applied to measurement solutions.

2. Missing data: missing data, with rare exceptions, always reduces calculated performance.

• eCQM process requirements are rigid. The process is susceptible to user compliance with strict standards. Every deviation from the standard has the potential to reduce calculated performance.
• MIPS CQM processes tend to be more flexible. Any reliable data source is usable. Search terms can be broadened and customized. Data can still be missed, and missed data still reduces calculated performance, but it is far more flexible.

Question Two: Using MIPS CQMs for APP after 2024

Jane asks: “Our compliance department has advised that eCQMs will be the only valid method for APP quality reporting after 2024. What is the evidence that we will still be able to use MIPS CQMs?”

I find it to be a common misperception that Medicare will eliminate the MIPS CQM submission option for the APP after 2025. I’ve never heard Medicare say it, but I’ve heard it frequently from those trying to interpret Medicare communications.

I think the misperception comes from the concurrence of messaging about the rules and concrete plans for the APM Performance Pathway and the simultaneous but unrelated introduction of the concept of Digital Quality Measures.

The Final Rule for 2022 for the Quality Payment Program was a big year for the APP. Medicare slowed the transition to the APP and memorialized its plans into rules. By 2025 all MSSP ACOs must stop using the Web Interface and participate in the APP using eCQMs or MIPS CQMs.

In that same Final Rule for 2022, Medicare introduced the relatively unrelated concept of Digital Quality Measures.

Digital Quality Measures were introduced by requesting comments on the provocative statement:

“We aim to move fully to digital quality measurement in CMS quality reporting and value-based purchasing programs by 2025.”

Two things have happened since then:

1. In March 2022, Medicare released a “Digital Quality Measurement Strategic Roadmap” document. The document nicely reviews the barriers to Digital Quality Measurement and a framework for getting there.
2. The Final Rule for the Quality Payment Program for 2023 was released in November 2022.

The published strategy and the 2023 rulemaking did not mention any further expected cutover date to fully digital quality measurements.

And I’ll refer you to the Code of Federal Regulations at Part 425, pertaining to the Medicare Shared Savings Program, Subpart F on Quality Performance Standards and Reporting, Section 425.512:

• “(iii) An ACO will not meet the quality performance standard or the alternative quality performance standard if:
  • “(A) …
  • “(B) For performance year 2025 and subsequent years, the ACO does not report any of the three eCQMs/MIPS CQMs and does not administer a CAHPS for MIPS survey under the APP.”

This rule confirms that MIPS CQMs and eCQMs will continue to be available after the sunset of the Web Interface option after the 2024 Performance Year.

There is no date set in Medicare rules after which MIPS CQMs will not apply to APP quality reporting.

I note that fully digital measurement is not a legislated requirement. For Medicare, digital quality measurement is a strategic wish-to-have rather than a legislated must-have functionality.

And finally, I’ll mention that a similar dynamic started playing out in 2015 when in the final rule for the Physician Quality Reporting System for 2015, CMS declared that the Claims Measures option would end at a to-be-determined future date. After eight subsequent rulemaking cycles, that sunset date has yet to materialize.

Question Three: Identifying “All Patients” for APP Reporting

Mike asks: “When identifying ‘all patients’ for APP quality reporting, is that based on the TINs associated with the ACO or providers/NPIs associated with the ACO?”

A provider, relative to Medicare’s Quality Payment Program, is a TIN-NPI.

A provider is a different entity, as far as quality reporting is concerned, in each TIN. So we’ll be looking for all patients of all providers of all participating TINs in the ACO.

Question Four: Unusual ACO Structure and APP Measures/Attribution

“We have an unusual ACO structure in which we set up new regional practices with new TINs in which we are enrolling participating providers. All ACO patients and only ACO patients will be seen in/by these TIN-NPIs. How will this structure affect measurement requirements? And, how will it affect attribution?”

That’s an interesting application of the model and should help ease and clarify your project.

It makes a lot of sense, and I see how this qualifies as a distinct business and warrants a distinct TIN and business structure. However, Medicare could consider it a loophole, and you may see it closed eventually.

Regarding attribution:

• It will have little effect. All of your ACO-TIN patients will be with the ACO. But not all ACO-TIN patients will be attributed to the ACO.
• It will work differently with prospective than with retrospective attribution:
  • In prospective attribution, most of your ACO-TIN patients will be attributed to the ACO because the differentiating factor is choice. Patients choose to be in the ACO, which is not affected much by engagement or comparative visit volume.
  • There are still some dynamics that patients may withdraw from the ACO, still engaged with the practice but not attributed.
• With retrospective attribution, the plurality of care is the deciding factor. All patients of the ACO practice are eligible to be attributed, but only those getting more primary care from your ACO-TIN practice than any other practice can be attributed. So more patients will be in the practice than attributed.

Regarding the APP measures:

• Because the ACO-TINs and NPIs will serve only patients of your ACO, you will effectively avoid some of the difficulties usually encountered in all-patient, all-payer quality reporting.
• It is still a very different experience from Web Interface Reporting.
  • All patients, attributed or not, must be included in the denominator.
  • And the numerator status has to be known and reported for at least 70% of them.

Question Five: ACO Providers in Multiple TINs

Gwen’s next question: “Many of our providers are working with two TIN Practices. One of those TIN practices is working nearly exclusively with our ACO and Medicare-covered patients. They do similar work for other TINs for patients of Medicare and other insurers but not connected to the ACO. Is there a need to reach out to those other practices to collect data to report on patients of other insurers?”

An NPI is typically a TIN-NPI to Medicare.

They are a different entity with different quality reporting obligations within each TIN in which they work. ACO quality reporting under the APP is specific to the patients seen by all TIN-NPIs, billed by the TIN participating in the ACO.

The patients seen by your NPIs in any other TIN practices not participating in your ACO are irrelevant to your APP quality submission.

Question Six: APP Reporting with Hospitalists

More from Gwen: “We have several TINs in our ACO that have two lines of business: they participate in our ACO, and they serve their local hospitals as hospitalists. For our APP quality reporting, do we need to include all of the patients from the hospitalist line of business that are not engaged with our ACO?”

The answer is yes and no.

You need to report on all eligible patients for each of the three APP measures from all patients of all payers in each of your participating TIN practices.

For quality reporting, whether patients attribute to the ACO or not does not matter. If there are patients eligible for these measures in these TINs, they will need to be reported—subject, of course, to the 70% data completeness requirement.

On the other hand, only some hospitalist patients in those practices should be eligible for any of the APP measures. A quick look at the measure specifications suggests that no ER, hospital inpatient, or hospital outpatient visit codes are included in the measure eligibility specifications.

Our thorough analysis of your billing data will show if any unanticipated coding practices or practice dynamics extend your reporting liabilities beyond the ACO patient group.

Question Seven: Asking Providers for Data

Gwen also asks: “We are a new MSSP ACO, still recruiting practices, and working through the requirements and setting up our processes. We are expecting it to be a ‘tough sell’ to ask our providers for all of their patient data to fulfill the all-patient, all-payer quality reporting requirements. Do you have any advice for us?”

Gwen, I feel your pain.

Likely, you will have a smaller problem than you expect.

Whatever outrage there’s been, I’ve seen it directed at Medicare, not the health organizations trying to meet Medicare requirements.

This issue first arose in 2017 when 3/4 of providers shifted from PQRS to MIPS.

For most of MIPS, all-patient, all-payer quality reporting has been mandatory since the beginning. I was expecting a significant outcry, but it seemed no more than a whimper as CMS asserted its rights to get what it wanted.

Critics have been somewhat mollified by the observation that Medicare rarely sees patient-specific data for non-Medicare patients. It only happens in the compliance/audit process.

And you could kick the can further down the road:

• You have only a 70% data completeness criteria. You can create a compliant submission without collecting data from the top 30% of most aggressive objectors.
  • But this creates a double standard in your ACO in which up to 30% of your providers contribute less than the rest.
  • And the reprieve is only temporary. Medicare will gradually increase the data completeness requirement.
• You can use the Web Interface technique for the 2023 and 2024 Performance Years.
  • That restricts your reporting requirement to Medicare patients attributed to your ACO.
  • But you won’t be improving your data flow to help assure accurate measurement of high performance by the 2025 Performance Year, for which you must deliver all-patient, all-payer performance metrics that fully meet the quality performance standard. You won’t collect your share of your savings if you don’t.

I recommend a straightforward and factual introduction to the quality reporting requirement. You have no choice in the matter, and your ACO can’t function and collect its shared savings if it doesn’t comply with Medicare’s all-patient, all-payer reporting requirements.

And finally, there are two roles that we at Mingle can play in this:

• Often, a big part of the objection is sharing deep intimate performance data with local peers that may be partners in the ACO venture but competitors in other business lines.
  • We are a disinterested third party who can collect and process the data, giving administrative access only to the aggregate data but not to the intimate details.
• We also can help to communicate, as experts in the Medicare rules, the facts of the requirements and options.

Question Eight: Data Security for ACOs

Gwen’s final question: “We expect our providers to be concerned about the security of their data. How does that work?”

For our client ACOs and their practices, we serve as an unbiased 3rd party to hold and handle the data. Data comes electronically to Mingle Health by secure transmission. It’s encrypted in transit and encrypted in storage.

We automatically strip identifiers from the data, replacing the public identifiers with proprietary ones. We do all of our storage, work, and validation on deidentified data, reidentifying it only on return to the source to assist practice data validation, data improvement processes, and analysis of gaps in care.

We maintain a highly secure environment with a commitment to SOC-2 level security processes and certification.

We serve under a Business Associate agreement with your ACO and practices, with a HIPAA-defined need for data access relating to payment and operations.

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.

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