In this edition of Ask Dr. Mingle, Dr. Dan Mingle answers questions from Carrin and Laura about:

• The future sunset of MIPS CQMS and if this will mean mandatory eCQMs for reporting to CMS
• And instances when the Medicare patient list provided by CMS for Medicare CQMs may be helpful for ACOs transitioning from the Web Interface

Click play on the video below to listen to this episode now:

Question One: MIPS CQMs Sunset & Mandatory eCQMs

Carrin asks: “Are you able to tell us the year that MIPS CQMs will sunset and eCQMs will be the mandatory reporting method?”

CMS has not published a plan or time frame for the sunset of MIPS CQMs.

Many people infer from Medicare’s published Digital Quality Strategy that there will be a sunset and a complete switch to mandatory eCQMs.

I think the switchover to mandatory eCQMs is unlikely. More likely, the requirements of both methods will evolve in a converging pathway, possibly ending in a single type of measure that is not entirely like any of the current methods.

I don’t think that expertise today in either eCQMs or MIPS CQMs is more likely than the other to prepare you for what measure type or types are supported 5, 10, or 20 years from now.

MIPS CQMs are deeply embedded in Medicare’s Quality Payment Program. Ending them would not be trivial. More likely, they will not end; they will only evolve.

MIPS CQMs are necessary for MIPS Value Pathways (MVPs), which have a 10-year ramp-up ahead. A review of the MVP measure choices shows that MIPS CQMs are pivotal to the MVP infrastructure. Re-engineering MIPS CQMs to the eCQM style will require massive work.

For those without EHRs, MIPS CQMS are vital. There is no sign that the exemptions for small practices, non-patient-facing, or facility-based providers will disappear soon.

In these cases, MIPS CQMs are a requirement, and mandatory eCQMs would not work.

Creating and maintaining a set of specifications requires a lot of effort. The disseminated network that builds and maintains measures is still doing it more actively for MIPS CQMs than for eCQMs. There are 42 eCQMs and 172 MIPS CQMs. Redirecting that effort will not be trivial.

Let’s look at other changes in our experience:

• Medicare announced in 2013 that Claims Measures would be sunset. They have not yet.
• In 2020, Medicare announced the expected sunset of Web Interface reporting.
  • Finally, in the first quarter of 2025, we will build our last Web Interface submissions.

My advice is to choose what is best for you today. Change if and when you need to.

You should have your own digital strategy. Such a strategy will prepare you for any future I can conceive of in quality measurement.

Work on your systems – particularly your digital systems – to:

• Improve the quality of your care.
• Document your high-quality care.
• Accurately measure your high-quality care.

The things you learn, the skills you improve, and the systems you develop will apply to any method of reporting that Medicare supports or demands today and in the future.

Choose your reporting method based on what is available and achievable and what makes you competitive today.

If you spend money on an attempt to predict Medicare’s future decisions, you risk wasting time and money and gamble underperforming in your quality measurement.

I suggest you do what works and change if and when necessary.

Question Two: Medicare Patient Lists for Medicare CQMs

Laura asks: “We are an ACO making the switch off of Web Interface. We are planning to use the new Medicare CQMs. Is it required that we use the patient lists that Medicare provides as our denominator?”

As you know, Medicare introduced the new Medicare CQMs collection type in rule-making for 2024. CMS designed the collection type to ease Accountable Care Organization (ACO) conversion from Web Interface into full-on APM Performance Pathway (APP) reporting.

A key to a successful APP submission is the identification and deduplication of patients across all practices in the ACO.

As part of the Medicare CQM offer, Medicare also offers to give each ACO a list from their data of all patients in the ACO eligible for Medicare CQMs. The list from Medicare will be correct because they naturally hold a complete and deduplicated data set as an essential part of the health care payment system.

But I’m seeing two pieces of critical misinformation circulating about Medicare CQMs:

• You have to use Medicare’s generated patient list. You don’t.
• It includes attributed patients who haven’t been seen. It doesn’t.

A big part of the problem is unusually vague and misleading provider-facing collateral from Medicare on this subject. Over the years, I have watched Medicare dramatically improve the quality and clarity of guidance documents prepared for Quality Payment Program participants.

The documentation for Medicare CQMs is not yet up to Medicare’s new standards.

To truly understand the Medicare CQM requirements and options, you need to have deep knowledge from a variety of sources.

The important sources:

• Medicare rules
• Medicare CQM measure specifications
• And Medicare’s topical guidance document called: “2024 SSP ACO Medicare CQM Checklist”

In the Medicare Rules:

In the Electronic Code of Federal Regulations, the official home of the historical and current rule set, Medicare CQMs are defined at: “§ 425.20 Definitions: Beneficiary eligible for Medicare CQMs.”

The language is dense, but it boils down to two parts:

1. Medicare Part B patients seen by an ACO primary care provider in the performance year, whether attributed to the ACO or not.
2. Medicare Part B patients who have been attributed to the ACO, whether they have been seen or not.

This clearly describes Medicare’s intent with Medicare CQMs, and taken at full face value, it suggests that you have to use Medicare’s patient list because it’s the only source of patients who have been attributed but not seen. That status can only be achieved through prospective alignment by patients who choose your providers as Primary.

That is an important detail on the surface.

However, it is modified when considering the next source, the measure specs.

In January, Medicare published measure specifications in the usual form and format for the three APP measures as Medicare CQMs.

The specs are incomplete. Other than labeling each of them as Medicare CQM specs, they are word-for-word duplicates of the MIPS CQM specs.

I’d like them to mention the important denominator restriction to Medicare Part B patients. From the rules and the Federal Code, we know the denominator is restricted to Medicare Part B patients, but we wouldn’t know it from reading the specs.

The critical factor the specs introduce is that the denominator is limited to patients seen at least once during the performance year. This factor eliminates the attributed but not seen patients from the calculations.

That brings us to the final document.

In my search of the QPP resource library, I found one summary document on Medicare CQMs. The “2024 SSP ACO Medicare CQM Checklist.”

This document exclusively focuses on the Medicare-provided eligible patient list. To the casual observer, it suggests that you must use Medicare’s provided list. It’s only detailed knowledge of the 2024 Final Rule and the Code of Federal Regulations that we know otherwise.

And one word in one sentence is key in that document. The last sentence of the first paragraph introduces the document as:

“This resource provides steps that ACOs may take to prepare for and successfully complete quality reporting via the Medicare CQM collection type.”

It takes some experience with Medicare specs to understand that Medicare takes the words “May,” “Should,” and “Shall” extremely seriously.

I think Medicare CQMs are a great resource and will provide valuable support for ACOs that have given up on electronic reporting and retreated to a manual chart abstraction collection style.

But there are two reasons the rest of you should not use this resource:

1. It’s late. Medicare is usually more than a quarter behind in releasing claims received data.

They pledge to be better with these patient lists, but the complete and final list will not be available until February. This is after the close of the performance year, leaving precious little time to pull a complete submission together using the list.

It’s the best thing to use if you will manually abstract charts.

However, you’d best abstract the charts quarterly, as Medicare provides the lists, so you are not left with little more than the month of March to create your submission.

2. Though I would describe it as the Gold Standard for your eligible patients, it adds more confusion than help in the typical project.

Our favorite place to get denominator data is from claims. We find that claims are nearly always accessible by even small practices as a byproduct of the claims submission process.

We observe that data sets always vary from one another. Patient identification is a chore:

• Spelling errors, formatting differences, differences in syntax, use of maiden vs. married names, name changes in marriage and divorce, and other name changes. Variations dealing with middle names or initials, common use of the middle instead of the first name, nicknames vs full names.

Dealing with it becomes delicate and tedious.

Medicare’s list may be the Gold Standard, but from the analysis perspective, it is just one more list that differs from all of the others.

Where “n” equals the number of claims data systems in your organization and “n” is directly related to the difficulty of identifying and deduplicating patients, using Medicare’s list makes that difficulty “n” + 1.

It is always more complicated with it than without.

In summary, using Medicare’s list creates a tedious need to reconcile their list with each of your member practices with precious little time to do it.

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 hello@minglehealth.com.