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Cost Drivers of Measure Options for the APM Performance Pathway & 4th Quarter MIPS Priorities | Ask Dr. Mingle

In this episode, Dr. Dan Mingle explains the cost drivers of different CQM options for organizations completing their ACO quality submission via the APM Performance Pathway (APP). Later, Dr. Mingle explains 4th quarter focus areas to optimize MIPS scores.

Click play to listen to this episode now:

Question One: ACO Quality Submission with CQMs

John asks: “We are preparing to convert to CQMs and the APM Performance Pathway for our ACO quality submission. What are the cost drivers to consider when looking at eCQM vs. MIPS CQM and Medicare CQM options?”

No matter how you generate your data – manual, electronic, QDC codes, secondary data sources, or a mix – accomplishing your ACO quality submission through a Qualified Registry is likely to be more affordable, scalable, and sustainable than EHR-generated eCQM submissions.

If you go the eCQM route, your quality submission must be entirely electronic and hands-free. Your HIT vendor will need to receive data from all your participating practices, deduplicate, aggregate, and submit your data to Medicare or provide you with a file you can submit.

Every step of the eCQM process, from documentation of care through data exchange to a shared repository to measurement and analytics, must be electronic and certified. Any break in that chain threatens the acceptability of the data (and your ACO’s quality submission).

The process could break if a previously certified step falls out of certification or one or more of your participants changes or upgrades their EHR.

You will utilize a quality registry for either MIPS CQMs or the proposed Medicare CQMs.

A qualified registry, like Mingle Health, can also submit your eCQMs if you have them.

If your data is already deduplicated and aggregated, we can accept and submit a QRDA 3 file for you. QRDA 3 files are the aggregate form of eCQM submissions. They contain no patient identifiers.

If your data still needs to be deduplicated and aggregated, we will want to use QRDA 1 files if you have them. QRDA 1 files are eCQM-compliant files that include patient identifiers.

  • Using QRDA 1 files, Mingle can combine your QRDA 1 data with other data types to build a deduplicated and aggregated ACO quality submission for your entire organization.

And we can use eCQM-compliant files from all of your ACO participants for your ACO quality submission. But we can offer additional advantages as well:

  • We can help protect your submission from IT certification issues – any step in your process that falls out of certification will not threaten the acceptability of your quality submission.
  • We can use any accurate data from your partners to build the qualifying submission. This could be:
    • Flat files from your EHR database
    • Manually abstracted data
    • Data generated by your EHR’s automated reporting system
    • QDC codes generated in your billing system
  • Our process allows for manual abstraction when needed. If manual abstraction is required to meet your data completeness requirements, you will find an advantage with Medicare CQMs. Needing only Medicare patients to complete a qualifying Medicare CQM submission, you will have to abstract fewer charts – a significant reduction in effort.
  • Using a capable Qualified Registry, like Mingle, you can select the Medicare CQM or MIPS CQM at any time in the process. You can change your mind until Medicare’s annual ACO quality submission window ends.

Question Two: MIPS Focus Areas in the Fourth Quarter

June asks: “What do you think should be our highest priorities in the fourth quarter of each year to optimize our MIPS scores?”

Let’s walk through the performance categories individually to highlight focus areas.

Promoting Interoperability (PI): By the fourth quarter, you cannot add much to your Promoting Interoperability score. You are down to your last possible 90 days to generate a final score. You can still get credit for exchanging data, ePrescribing, or checking your local PDMP (Prescription Drug Management Program) when prescribing controlled substances. Most measures take some development and implementation time, which is running out in the fourth quarter of the year.

Practice Improvement Activities (IA): Again, half of your providers need 90 days of participation to score on this activity. The fourth quarter is a little late to get started on anything new, and it is the last minute to get your participation up to 50%.

Cost: With 3/4 of the performance year now in the past, new cost-containment activities will have a negligible effect on your current-year scores.

Quality: Your most significant opportunity for improvement lies in your Quality scores. Like Cost, 3/4 of your performance year is already past, but there are still some important opportunities to optimize your scores.

Many Quality measures look for the most recent activity (like blood pressure, HbA1c, colon or breast cancer screening, and immunizations). If you have been monitoring your quality scores all year, the fourth quarter is an excellent time to generate a list of eligible patients who are not yet in the “Performance Met” status.

  • You should check charts to see that “met” performance is in your scores. If not, it’s an excellent time to correct your documentation so your measurement system picks up “met” performance.
  • Related to that, it’s a good time to supplement the training of your clinical staff so they document future care in a way captured by your measurement system.
  • If you are doing eCQMs, correcting your documentation is the only way to improve your scores.
  • If you are doing MIPS CQMs through a registry, correcting your documentation is not your only means of improving your score:
    • Your registry may accept a spreadsheet of abstracted patient data to reflect your great care more accurately and improve your scores.
    • One of the main benefits of MIPS CQM over eCQM reporting is combining data sources, including digital and manual collection techniques, for a more accurate blended quality submission.
    • Your spreadsheet must include the pertinent patient identifiers, the date the observation was clinically generated, and the nature of the observation.
    • You want enough data in the spreadsheet if you need to return to the chart and prove the measurement if CMS audits your submission.
  • If a patient without “met” status will be coming in soon, you can provide and document the “Performance Met” care before the end of the year.
  • And don’t forget that many measures can be “met” if you provide the intervention remotely or not face-to-face.

In review: the fourth quarter of each performance year is a great time to improve your Quality scores by:

  • Double-checking your Quality scores
  • Providing missing elements of “Performance Met” care in a visit or non-visit method
  • Finding and correcting documentation errors
  • Supplementing your registry submission with manually abstracted quality data.

Though you have limited opportunity to improve your scores for the other three performance categories (PI, IA, and Cost), the fourth quarter is a great time to generate a wish list for next performance year improvements.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, 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

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

For many ACOs, the transition to all-patient, all-payer quality reporting is a significant challenge and often feels like an unnecessary burden imposed by CMS. We've created our latest PDF guide to help ACOs orient themselves to the challenge of all-patient, all-payer reporting while finding opportunities to thrive in the future.

Access the Guide
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