In this episode of Ask Dr. Mingle, Dr. Dan Mingle is answering a set of frequently asked questions we’ve received from ACO clients and prospects about the APM Performance Pathway (APP).

Click play to listen to this episode now, or scroll down for the written summary:

Part One:

Part Two:

Use the links below for quick navigation to individual questions answered in this episode:

1: Web Interface Reporting in 2024 2: Data Completeness & Paper Records 3: CQM Reporting Data Requirements 4: Future of APM Performance Pathway (APP) Measures 5: Medicare CQMS Benchmarks 6: APP Reporting: When to start? 7: ACO Member Practice Quality Performance 8: Differences in Web Interface Measures & APP Measures 9: Availability of Medicare CQMs 10: End of MIPS CQMs or eCQMs 11: Gaps in Care 12: Information for Exclusion Criteria

13: Number of NPIs and APP Reporting 14: Obtaining Data with Limited Technological Capabilities 15: ACO Member Practice Communication and Education 16: Manual Abstraction Required for eCQMs and CQMs 17: Quality Performance Levels Before APP Reporting 18: MIPS Before Joining an ACO 19: Mingle Health vs. EMR Solutions for APP Reporting 20: When is it too late to start?

Question One: Web Interface Reporting in 2024

Frequently asked: “Is Web Interface reporting still available for the performance year 2024?”

Yes. 2024 is the last year of the Web Interface.

Those of you who decided to stick with it or to do CQM and Web Interface submissions together will be building your last Web Interface submission in the first quarter of 2025. Expect the due date to be March 31, 2025.

Everyone knows Medicare can grant a last-minute reprieve in 2025 rulemaking, but this seems extraordinarily unlikely. It takes effort for Medicare to keep that system going. With the investment CMS has made in the change to the APM Performance Pathway (APP) and the lack of investment in continuing the Web Interface infrastructure, I don’t see much chance of a chance.

You must report via the APP using MIPS CQMs, Medicare CQMs, or eCQMs in the first quarter of 2026.

There are three urgent reasons not to wait until the last minute to engage in the APP reporting process:

• First, in years past, we at Mingle Health have been known to engage a large group in February and complete a quality submission by March 31. But it would be foolish to count on that in this environment.
  • Nearly half of MIPS-eligible Medicare providers are in ACOs that need to switch to CQMs. Registries like ours are expanding staff and infrastructure as we engage new clients. There will just be too much competition for Registry capacity to be sure of finding capacity even in mid- to late-2025.
• Second, with the mixed-technology environment of most ACOs, it is not a trivial matter to get and blend data from all practices.
• Third, even if you are doing a great job providing high-quality care to all of your patients, your documentation may not necessarily be easy to access for accurate reporting.
  • You will need time, counted in years, to steadily identify and correct gaps in documentation. With all of your shared savings on the line, you are already late getting started.

Question Two: Data Completeness & Paper Records

Frequently asked: “What are the options for meeting the 75% data completeness requirement for CQMs if one practice uses paper records?”

By now, most of you know that Medicare requires you to access data and report clinical quality for at least 75% of eligible patients. Your submission will be invalid if your reporting falls below that 75% data completeness threshold.

And there goes the shared savings.

There are many great reasons to choose to submit MIPS CQMs or Medicare CQMs over eCQMs, and this is one of them.

Your registry, building a MIPS CQM or a Medicare CQM quality submission, can blend manually abstracted data from your practices on paper charts with electronically extracted data from your practices on Certified EHR technology.

In our experience, the likelihood of being on an EHR increases with practice size. It’s likely to be your smallest practices that are still on paper charts. In many ACOs, less than 25% of patients are seen in non-EHR practices. If you fail to get data from your practices on paper, you may still meet your 75% data completeness threshold.

I would not, though, suggest that you give your practices on paper a “pass” on this requirement. Expect or contractually require them to contribute to the ACO quality reporting effort.

Your practices on paper charts should expect to have to manually abstract charts to do annual quality reporting. Keep that expectation.

You might need to “spend” your 25% data incompleteness allowance on your practices with EHRs from which it is difficult to extract data.

You will also find that many providers on EHRs are not documenting data where you can easily extract it. Some of your practices on EHRs might best meet quality reporting requirements by manually abstracting their charts.

And this is where you should be thinking of Medicare CQMs. With Medicare CQMs, you are only reporting on Medicare patients. On average, that is a little less than a third of the number of charts to abstract compared to a MIPS CQM submission.

To link this back to other conversations on APP reporting challenges, you should address this contractually in your Data Governance requirements.

For the foreseeable future, small practices will continue to get a pass from Medicare for the requirement to use Certified EHR technology. Your ACO should not. Everyone in your ACO should have a plan and steadily work toward implementing Certified EHR technology.

And though you might spend some of your data incompleteness allowance to build a successful year-to-year submission, you should still contractually expect all of your practices to contribute data.

Question Three: CQM Reporting Data Requirements

Frequently asked: “What data files or transfers do we need for CQM reporting?”

Your MIPS CQM or Medicare CQM APP submission will require:

• Claims data
• Clinical data
• Specific clinical data being:
  • Vital signs for the Blood pressure measure
  • Lab results for the Hgba1c measure
  • Depression screening test results and depression-related orders or services for the depression measure

The foundation of accurate reporting is an accurate denominator.

We get denominator data from claims. There is no better source from which to understand who the patient is, what problems they have (ICD diagnoses), what services they received (CPT, E&M, and procedure codes), and who the insurer is. Identifying the insurer is not important for MIPS CQMs but is essential for Medicare CQMs.

The great news is that we can use your billing records to access these files. Practices may know where to find them in their systems, or they can be guided to them by their technology partners or billing/revenue cycle partners.

Clinical data, like vital signs and labs, are usually straightforward extracts from the EHR.

The two data sets for depression measure reporting can be more challenging. There is no standard location in electronic charts for screening and management data. The depression measure, however, has been around long enough that most EHR users have an infrastructure we can tap to get this data. Providers may not use it effectively, which is one of the chief reasons to engage with your registry early to identify and correct gaps in that data flow.

Question Four: Future of APM Performance Pathway (APP) Measures

Frequently asked: “What is the future of APP measures beyond the three currently required?”

Great question. There are no published plans or scheduled dates for a change in measures.

However, the measures currently required aren’t set in stone. They can change.

The count of measures, currently three, can also change. It can go up or down, but up is more likely.

You can count on change, however. Medicare has two statutory requirements:

• Choose measures that differentiate the market.
  • The biggest risk to this is topped-out measures.
  • As everyone gets good at any one or more of the measures, Medicare will have to choose new measures to maintain a range of ACO scores.
• And Medicare is required to use measurement to drive improvement.
  • New measure choices will come from perceived system needs and priorities and the perception that there is room for improvement.

There is no question that the specific measures will change. And maybe the number of measures.

Question Five: Medicare CQMS Benchmarks

Frequently asked: “Where do we find benchmarks for Medicare CQMs to guide our development efforts?”

They don’t exist. It will be at least two years before we have pre-published benchmarks. Until then, Medicare will calculate performance-year benchmarks from the data submitted in that year. You can’t know how you will score until Medicare completes the calculations.

But you should expect Medicare CQM benchmarks to be more competitive than benchmarks for MIPS CQMs.

If you submit MIPS CQMs (or eCQMs), Medicare will compare you to all other submitters in the nation. The benchmarks will be based on all practices submitting those measures, whether ACO or not.

Medicare CQMs will only be submitted by other ACOs; a group incented to do better to keep their shared savings.

With MIPS CQMs, all ACOs can perform well enough to keep their shared savings.

With Medicare CQMs, it is a mathematical requirement that some ACOs will be poor performers and fail to keep their shared savings.

It might be a tough decision from year to year. And you may want to submit both:

• Your Medicare CQMs will better reflect your practices on paper or data-impaired EHRs.
• Your MIPS CQMs may have more favorable benchmarks, though they may be challenged on Data Completeness criteria.

Question Six: APP Reporting: When to start?

Frequently asked: “How important is early engagement in the APM Performance Pathway (APP) reporting process?”

Medicare has kept ACOs relatively protected from difficult quality reporting so far.

Web Interface measurement is almost universally a manual chart abstraction process. You can facilitate it by electronic abstraction, but it is difficult without substantial manual chart abstraction.

We find that measurement by chart abstraction tends to be more accurate than electronic extraction.

That is because providers prioritize accuracy and ease of entry over standard language and accessibility when they document. When manually abstracting charts, those doing the abstraction are, or become, adept at finding the data no matter where or how providers record it.

Electronic extraction is inflexible. Tiny aberrations in style or location render the data undetectable.

Identifying and correcting those data aberrations is time-consuming. The process is not quick and straightforward; it requires continuous vigilance to maintain, and there is typically continuous opportunity to find and eliminate errors.

This is to say: start the APP reporting process as soon as possible to give your ACO the greatest chance of success.

Question Seven: ACO Member Practice Quality Performance

Frequently asked: “Does it make sense to monitor new practices for quality performance before they join the ACO?”

Absolutely!

Before a new practice joins your ACO, you should know how they are performing on the measures important to you.

That should include the current APP measures. But there may be others that matter to you.

It is a great idea to require the three APP measures to be used for MIPS in at least the year before inclusion. They can be the 7th, 8th, and 9th MIPS measures, or part of the required 6.

If you are engaging Mingle to help with your APP reporting, it’s even better to require your candidate practices to engage Mingle for MIPS for one or more years before joining. We can do the first pass or two to engineer their data flow before you include them in your ACO APP submission.

Question Eight: Differences in Web Interface Measures & APP Measures

Frequently asked: “The Web Interface requires ten measures. The APM Performance Pathway only requires three. What happens to the other seven measures?”

They no longer affect your APM Quality standard or contribute to your keeping or losing your shared savings.

You can always submit extra measures, but they will not affect your quality standard and will not result in an adjustment to your Medicare reimbursement.

Other measures may be important to you and your patients. At Mingle Health, we are delighted to track more than just the three APP measures with you.

Observing that we improve what we measure, any extra measures you do bring additional value to your patients.

And generically, practicing measurement makes you better at it and can prepare you for the next change in APP requirements, even if you don’t accurately predict the next measurement requirement.

Question Nine: Availability of Medicare CQMs

Frequently asked: “How long can we expect Medicare CQMs to be available?”

Great question, and the answer is entirely unknown.

Medicare introduced Medicare CQMs as a temporary construct to help ease the transition into APP CQM reporting.

But, other than describing it as temporary, they did not propose a sunset date.

It could as easily be permanent, or it could sunset in three years.

It depends significantly on how deeply you rely on them and your comments about them within your lobbying efforts and in your responses in annual rulemaking.

Question Ten: End of MIPS CQMs or eCQMs

Frequently asked: “Will eCQMs or MIPS CQMs be sunset someday, leaving us only one choice?”

Great question, and another completely unpredictable answer.

It would be hazardous to choose a submission mechanism today based on what you think will be required in the future.

No matter what CMS labels the submission mechanism required at some hypothetical future date, I don’t think we can predict what that mechanism will look like.

We know that the whole system is going to be subject to the annual cycle of rulemaking continually.

Changes in the rules will continue to be driven by observed changes and deficits in the system.

All CQMs will evolve. Some of the evolution may be convergent. Some may be divergent.

I strongly recommend that you do what will work best for you today. Change as required by annual changes in the rules.

It still makes the most sense to me to go the registry route with MIPS CQMs/Medicare CQMs.

A registry gives you all the data options that eCQMs give you without being limited to those options. By reporting MIPS CQMs or Medicare CQMs with a registry, you can improve your scoring today, accommodate the broadest possible candidacy for practices to join you and maintain all your skills and mechanism options for the future.

Question Eleven: Gaps in Care

Frequently asked: “How can we address identified gaps in care for paper practices?”

It makes excellent sense to me to use your quality analyses to improve your performance.

And it needn’t look much different, at its highest level, for paper vs. electronic practices.

We should exchange data between your ACO and Mingle Health at least quarterly, perhaps as often as monthly. You’ll provide the latest claims and clinical data, and we will process the quality performance analyses using the same logic we apply to the final annual report to Medicare.

You will have access to a year-to-date quality performance score on each measure on our dashboard, with the ability to view:

• Scores by practice
• Scores by provider
• And performance for each patient on each measure

I suggest you download a list of patients in the “Performance Not Met” status for each measure for each practice. Someone should work those lists. It may be someone in each practice or a central resource for the ACO. There are many options; you will want to choose what works best in your environment:

• You can provide remote services, testing, referral, or medication adjustment
• You can accelerate the next visit to address the gaps
• Or add a note to the chart or the schedule to fill the gaps at the next visit

You can achieve the best performance using analytics to inform your next encounter.

Question Twelve: Information for Exclusion Criteria

Frequently asked: “How do we get information, like dispensed medications, to meet exclusion criteria for specific measures?”

There is an enormous list of potential data sources to identify exceptions.

Commonly, exceptions can be found in:

• Medication lists
• Allergy lists
• Problem lists
• Results
• Vital signs

Almost any data set in an EHR can contain exception data.

As long as the data is machine-readable and identifiable to the specific patient, you can provide us with structured data to identify the exceptions.

You don’t have to find it all.

Two critical processes that go hand in hand for finding this information:

• First, where and how far will you look?
  • For each measure:
    • What are the acceptable exceptions?
    • How can we identify each exception?
    • How accessible is the exception data?
    • Is it worth the effort? – How much will your effort affect your scores?
  • You don’t need to find it all. You need to set limits based on your perceived or measured cost-benefit.
    • I have never seen Medicare audit or discipline a practice on what it did not find or look for.
    • If you claim performance is met or an exception exists, you should be able to send Medicare a copy of the data that says so.
  • I have never seen Medicare ask for proof that an intervention, an exception, or a measurement does not exist.
• Second, hand-in-hand with limiting where and how far you look, standardize your data collection to improve your capture and accessibility of exception data continually.

Question Thirteen: Number of NPIs and APP Reporting

Frequently asked: “Does the number of NPIs affect the quality reporting process?”

In one sense, no, it doesn’t.

Whether one or one thousand NPIs are represented in the measure, the output is structurally the same:

• The denominator is the count of patients for whom the measure is indicated.
• The numerator is the count of patients for whom performance is met.
• Within this, there are:
  • Exceptions
  • Exclusions
  • The reporting rate
  • And the performance rate

On the other hand, more NPIs give:

• Bigger numbers of patients
• More variation in documentation practices
• More complexity in data collection
• Larger data sets to exchange
• And a bigger job to appropriately identify and deduplicate the patient population

There are four kinds of reporting that we are now doing at Mingle Health:

• Individual – one NPI at a time
• Group – one TIN at a time
• MIPS Value Pathways (MVPs) – multiple groupings of NPIs from each TIN
• APM Performance Pathway (APP) – Multiple TIN practices with some/all of their NPIs from each ACO or APM

Each step up in that list represents a higher level of complexity in:

• Collecting data
• Analyzing data
• Displaying data

The number of distinct information systems is the most significant complexity driver in any quality reporting effort. The independent selection and maintenance of information systems drive the complexity in large numbers of TINs.

Even the same EHR implemented and maintained in separate instances significantly adds to complexity.

Question Fourteen: Obtaining Data with Limited Technological Capabilities

Frequently asked: “Do you have difficulty obtaining data from smaller practices with limited technological capabilities?”

Yes and no.

At Mingle Health, we have always taken all comers, from small practices with limited technological capabilities to large practices with abundant technical skills and resources.

We have developed workable processes for each variation.

We love the push-button simplicity of electronic quality measurement. However, it is never as easy and foolproof as we would like.

There are common holes in the data, leading to underestimation of performance, like:

• Lack of Structured documentation
• Lack of Documentation standards
• Absent elements, such as exceptions
• Data held in text
• Data received as fax or PDF document

Small or large practices on paper or an EHR without the access or capability of extracting the data fall back on chart abstractions.

Chart abstractions can be complex. You need to understand which patient charts to pull, and each measure might require an enormous number of chart abstractions.

But once extracted and transmitted to us in a spreadsheet format, it’s just as easy, if not easier, to process it as electronically extracted data. It tends to be more accurate with better performance documented than the typical electronically extracted measures.

Question Fifteen: ACO Member Practice Communication and Education

Frequently asked: “How much time is required for member practice communication and education regarding APP requirements?”

We certainly see a lot of variation in how much training and support each ACO gives its practices, and adequate training and support pays off with better performance scores.

A good hour with a knowledgeable resource should give an adequate understanding of the basics. However, generating accurate and great metrics requires a deeper knowledge and goes beyond an understanding of the specifications.

The numerator and denominator specs of each measure are a good starting point. It is important to understand the documentation workflows and variations in those workflows. Cataloging the location, in your specific system, of the data you need is required.

The access rights and skill to locate the data and transmit what is wanted and needed are also important. There can be both business and security barriers to accessing the data, and there are often factors controlled by entities outside your practice, such as:

• The EHR vendor
• The data host
• Or other intermediaries

Knowing who to ask and how to get access may be more complex than acquiring the tools and skills.

You are in the right ballpark to devote an hour monthly to focus on training, education, and problem-solving. I like group processes, where everyone meets at once:

• Everyone hears the same thing at the same time
• Questions are asked that everyone needs to know, but only one person thought to ask
• Important lessons are shared about how practices get access to their data
• You develop your shared support as your group gets to know each other and gets comfortable asking for help and helping each other

Question Sixteen: Manual Abstraction Required for eCQMs and CQMs

Frequently asked: “What is the difference between eCQMs and CQMs and the level of manual abstraction required for each?”

The concept of manual abstraction is the first thing that leaps out of that question.

If you need to or want to do manual abstraction you cannot do eCQMs.

eCQMs are electronic only. No abstraction allowed.

The electronic data for eCQMs can only come from certified EHR technology – CEHRT. If want to report electronically from a secondary source, like a diabetes registry or a cardiovascular registry or a laboratory information system, you can’t do eCQMs.

I think that there are commonly used systems that put your eCQM submission at risk.

We commonly use practice management system data to generate denominators and commonly get data from reporting databases or clinical data repositories for numerator data.

If you use those systems as part of your eCQM submission generation, your practice management system and/or data repository may not be CEHRT. They could put the validity of your submission at risk.

Medicare would not notice unless it investigated your submission technique thoroughly. Thus, successful submissions in the past may not be adequate assurance of continued success.

Now, a little bit more on the differences.

When referring to CQMs, I think MIPS CQMs and Medicare CQMs. They work off the same specifications and dynamics, except MIPS CQMs draw from all patients and all insurers of all practices in the ACO. Medicare CQMs only include Medicare Part B patients of all primary care providers in all practices in the ACO.

eCQMs use different specifications that are limited to standardized electronic clinical concept sets. eCQMs are all patients of all payers, and eCQMs must be all electronic with no manual selection or editing of the data.

The three techniques are each benchmarked separately:

• eCQMs are benchmarked and scored only in comparison to other eCQM submissions of the same measures
• Likewise MIPS CQMs are benchmarked and scored against other MIPS CQM submissions of the same measures
• Medicare CQMs will be benchmarked and scored against other Medicare CQM submissions of the same measures.

eCQMs are exclusive. You have to be all electronic for eCQM submissions. You can’t use any manually abstracted data, or manually edited data, and no electronic data from non-certified sources.

In contrast, MIPS CQMs and Medicare CQMs can use any valid data from any source. They can edit and combine data sources without any risk of invalidation. These CQM submissions can be all electronic from certified EHR sources. They can be all electronic data from non-certified sources. They can be all manually abstracted. They can be any combination of those sources.

Question Seventeen: Quality Performance Levels Before APP Reporting

Frequently asked: “Do providers need to know their quality performance level before engaging with Mingle Health?”

It isn’t necessary.

I view this question as an analogy to my years as a primary care physician. I never expected my patients to know what ailed them when they saw me.

Likewise, I see our role with our clients as bringing them to the point of knowing their quality performance levels. Our role is to help our clients measure, report, and improve their quality performance levels.

Question Eighteen: MIPS Before Joining an ACO

Frequently asked: “How do we incentivize providers to participate in MIPS before joining our ACO or in gap years between iterations of the ACO?”

The three measures of APP are standard MIPS measures in broad use.

Practices using those measures for MIPS before engaging in the ACO will be at an advantage—they’ll know the process, likely be more efficient in documentation, and have better score expectations.

You may consider sharing the cost of MIPS reporting for those practices in a gap year or who are in the year or years leading up to joining your ACO.

Practices can include the three APP measures in their six MIPS measures or submit them as three extra measures if they are more confident of better MIPS adjustments using other measures.

Not only do your practices get valuable experience, but you can go into the relationship with a foreknowledge of what you can expect the new practice to do to your scores.

I’m also inclined to think that performance should be reflected in practice revenues.

The ACO, optimally, will be earning shared savings. You will likely use those shared savings to build and/or maintain infrastructure and distribute some to the participants. I think the distribution should be favorably weighted to those contributing better performance metrics.

If you enter the relationship with a history of performance scores, you can incentivize the new practice with first-year terms reflecting their historical performance.

The work done by your new practices, engaged with Mingle Health before joining the ACO, will perfectly translate into data that we can blend into the ACO submission. All of the infrastructure, knowledge, and skills gained in MIPS efforts will be reusable for the APP efforts.

Question Nineteen: Mingle Health vs. EMR Solutions for APP Reporting

Frequently asked: “How does Mingle Health add value to the APP reporting process, compared to EMR-based reporting solutions?”

First and foremost, Mingle Health gives you flexibility. The value of this flexibility becomes evident as you try to meet the quality standard to generate full collection of your shared savings.

You will encounter many challenges in your measurement process, and typically, you’ll find solutions more easily through Mingle Health and the MIPS or Medicare CQM processes.

Part of the advantage of an EHR vs. third-party approach to data:

• Most ACOs have multiple TIN practices representing multiple EHR and practice management systems.
• EHRs do not play well together.
  • Most EHR vendors will say: “Of course we can handle your overall system needs. All you have to do is import data from all other EHRs in your system and translate it to our model.”
• They leave you with a monumental task – expensive, complex, and time-consuming – with too little support and a ready excuse for underperformance.

The other part of the Mingle Health advantage relates to the difference between eCQM and registry requirements and processes.

Remember, eCQMs are exclusive:

• You have to use Certified EHR technology, beginning to end
• You have to have the documentation templates precisely built
• Your providers have to use the proscribed documentation workflows
• You cannot manually manipulate the data in any way
• You cannot fill any holes with data collected in any other way from any other source
• And, eCQMs commonly fail as you try to blend data from multiple EHRs or even multiple instances of the same EHR

And MIPS and Medicare CQMs, in contrast, are flexible and inclusive:

• You can be all electronic and exclusively use CEHRT
• But you can also include data from any source collected in any way
• Your data simply has to be accurate, and certification is not required
• Electronic workflows are not required
• You can solve your problems in any fashion that works

Question Twenty: When is it too late to start?

Frequently asked: “When is it too late to start working with Mingle Health for APP reporting in 2024?”

The sooner, the better.

The later you start, the lower you’ll need to adjust your performance expectations.

We can build a technically effective submission for you within three months. That means a December 31st engagement will likely result in a submission by March 31st.

But there is a lot more you need to do than a technically effective submission.

Receiving a great score is not just a year-long process but a years-long (continuous) process.

The other factor you will be dealing with between now and March 31st, 2026, by which time all ACOs have to submit their APP quality data as MIPS CQMs, Medicare CQMs, or eCQMs, is an entire market that is in flux:

• About 1/3 of all Medicare providers will be competing for engagements with registry vendors who are all working to increase their capacity.
• If you wait too long, you may not get a seat at the table.

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.