In this week’s episode of Ask Dr. Mingle, Dr. Dan Mingle answers Jason’s question about when ACOs should begin the transition to MIPS CQMs/eCQMs. Later, he answers Linda’s questions about MIPS Value Pathways (MVP) dynamics in a multi-specialty group.

Click play to listen to this episode now:

Question One: When to Get Started with MIPS CQMs/eCQMs for the APP

Jason asks: “If we plan to use MIPS CQMs to satisfy the APM Performance Pathway (the APP), how soon do we need to get started?”

I’ll stratify my answer into three sets of circumstances:

1. ACOs for which eCQMs are the most cost-effective solution
2. ACOs for which eCQMs are feasible
3. And ACOs for which eCQMs are not feasible

If you are still struggling with this analysis, there are two resources where you might get some guidance:

• Medicare has published a Guidance Document discussing the APP reporting options and their strengths, weaknesses, and decision points.
  • “Reporting MIPS CQMs and eCQMs in the Alternative Payment Model Performance Pathways” is a good document with one of the most informed and accurate discussions I’ve seen from Medicare on this subject.
• You can also refer back to an answer I gave in a recent recording of Ask Dr. Mingle: “Are eCQMs right for me?“

The answer for all three strata outlined above is: The sooner, the better. It’s not too early.

But the rationale for my answer differs a little for each category. I’ll outline the specifics below.

The “eCQMs are the most cost-effective solution” category:

You might fall into this category if:

• All participants in your ACO share the same instance of a single EHR.
• Your EHR supports the three submittable eCQM measures of the APM Performance Pathway (APP).
• Your providers are skilled with your EHR and follow specified care documentation workflows.

So when should you start the transition?

Start now:

• The eCQM process is significantly different from the Web Interface Reporting process.
• As health care providers, we are much better at finding chart data on manual review than putting it in a standard location.
  • You want plenty of time to discover and correct anomalies in your documentation workflows.
• There are substantial scoring incentives to doing it early.
  • If your trial run of your eCQMs shows unfavorable scores for 2023 and 2024, you can submit both eCQMs and Web Interface and enjoy both the incentives for early use of eCQMs and benefit from the more favorable score of your two submissions.

The “eCQMs are feasible” category:

If you think eCQMs are feasible but do not enjoy the narrow circumstances I outlined for the first stratum, MIPS CQMs will likely be the most cost-effective choice.

So when should you get started?

Now:

• Every advantage I listed for the first stratum is just as applicable to you.
• If you apply yourselves to the task, with our guidance, or the direction of a similarly skilled registry, you can succeed with MIPS CQMs.
  • But if I were in your shoes, without the confidence I have from years of experience with MIPS CQMs, I’d want to leave time to re-engineer to eCQMs if it proves necessary.

And finally, the “eCQMs are not feasible” category:

Most of you fit into this category.

Your system is too complex and too changeable for it to be affordable to:

• Implement and maintain an enterprise master patient index
• Aggregate and normalize the EHR data from all or your participants
• And structure, standardize, and retrain care documentation workflows for all present and future ACO participants

MIPS CQMs are the most cost-effective method for most of you to meet APP quality reporting requirements.

But it still takes some time and effort to optimize your results. There are two data streams to engineer and optimize:

1. Your claims data: to identify 100% of your patient population for each measure denominator.
2. Your clinical data: from multiple sources to identify enough numerator data to satisfy data completeness criteria.

It’s doable. We have a lot of experience doing it. But the bigger and more complex your group, the more time it takes to run down and correct each identified gap or error. Do yourself a favor and start now!

Question Two: MIPS Value Pathways for Multi-Specialty Clinics

Next, Linda has several questions about MVPs.

For some context, before we get into Linda’s questions, she explains:

“We are a multi-specialty clinic. Suppose we would report on the Emergency Medicine MVP, as an example, to get our feet wet and report as a group (to include all specialties and the Emergency Medicine physicians). We understand that CMS would use the higher of the two scores in that case.”

Linda asks: “However, does that mean the entire group would get the higher of the two scores, or just the Emergency Medicine physicians since they were included in both reporting options?”

It seems unbelievable, but for the first three years of MVPs, your whole multi-specialty practice is eligible to get its quality score from a single, specialty-specific MVP.

It’s not so unbelievable when you look at sixteen years of quality reporting, first in the Physician Quality Reporting System (PQRS), then the Merit-Based Incentive Payment System (MIPS). Most multi-specialty groups have been qualifying the entire practice on primary care measures.

With that in mind, here’s a reminder on how to report an MVP:

• You have to register for it before the end of November.
• You have to define your subgroup.
• For 2023, 2024, and 2025 (the first three years of MVPs), your whole practice can be the subgroup, even if the measures don’t apply to most of them.
• You can only do one MVP per subgroup, even if your subgroup is the entire practice.
• But you can make a traditional MIPS submission, and your whole practice and subgroup will benefit from the higher scores.

Question Three: MIPS Value Pathways and Improvement Activities

Linda’s second question: “Would 50% of our group have to participate in any Improvement Activities, or just 50% of the group, excluding the Emergency Medicine providers who would have their separate IAs as a part of the MVP submission?”

For each submission, 50% of the providers scored on the submission need to participate in the selected practice Improvement Activities.

Since your whole group will be the subgroup, 50% must participate to get credit.

That should be easier than it might seem. My quick review of Improvement Activity choices shows that they are broadly applicable. I’d want to do a focused review for any of our clients intending to do that to ensure there are no surprises.

The other thing to remember is that it takes half as many improvement points for a full score in an MVP than it does for traditional MIPS.

To sum up: It needs some attention, but it should be manageable to choose MVP-specific Improvement Activities that apply to your whole group while satisfying the MVP. Then you will need one or two more, potentially, from the whole menu of MIPS Improvement Activities to meet your traditional MIPS submission requirements.

With the cross-functionality of all Improvement Activities and the number of choices for each MVP, you could choose all your IA activities for your traditional MIPS submission from the MVP set of options.

Question Four: Additional MVP Reporting Considerations

Linda’s next question: “Are there any other reporting considerations we should think of if we would attempt this combination reporting?”

It’s hard to be confident without knowing the unique attributes of your group, but I think it is pretty straightforward forward, and there are just a couple of other reminders I’d like to make:

• The registration window opens yearly on April 1 and closes on November 30.
• If you want to do the CAHPS survey (available in the Emergency Medicine MVP and three others), you must register for both the MVP and CAHPs survey by June 30:
  • Once you have registered, Medicare has told me that you can still change your choices and abandon the CAHPS survey or choose a different MVP and use the CAHPs survey for it if it is a choice for that MVP.
  • You can make those changes any time before the MVP registration deadline ends.
    • But if you miss the June 30 deadline, you can’t add the CAHPs survey later.
• From the context of your questions, I think you are already aware that a subgroup can only do one MVP. But it bears reminding everyone of that restriction.
• Until the eventual sunset of traditional MIPS, I expect that any subgroup you define and for whom you submit an MVP will get the better of the MVP submission score versus the traditional MIPS submission score.

Question Five: The Burden of MVPs after Traditional MIPS Sunsets

Linda’s final contribution is more of a concern than a question:

“Our practice includes ten specialties. When traditional MIPS sunsets and MVP reporting in subgroups is mandatory, I expect an enormous burden to potentially report on ten distinct MVPs, each having distinct and different Quality measures and Improvement Activity choices.”

That’s a genuine concern.

The legislation that established the Quality Payment Program demands an increase, over time, in the requirements. This is one of the ways that Medicare is implementing that increase:

• There is a submission requirement even for small and solo practices (with the exception of the low volume threshold, of course).
• Medicare sees the relative burden on you as no higher and potentially less than it is on those smaller practices.
• Looking ahead, I see a potential path in which all care is conceptualized in terms similar to inpatient Diagnosis-related Groups (DRGs). Reimbursement for any DRG will be modified by your performance compared to your peers.

Your only option is repeatedly giving your input as comments whenever CMS requests it. Every proposed rule and most, if not every, final rule comes with a formal comment period.

You are more likely to be successful at postponing the change or modifying the incremental uptick in burden, but ultimately, I expect the burden will increase.