This episode of Ask Dr. Mingle features a detailed overview of Medicare CQMs, a new collection type available for MSSP ACOs transitioning to the APM Performance Pathway (APP).

Press play on the video below to hear Dr. Dan Mingle and Laura Dietzel, Senior Clinical Informatics Analyst at Mingle Health, discuss Medicare CQMs and how ACOs can use them for quality reporting to CMS. If you prefer to read the questions and answers from this episode, please scroll down for the written summary.

Question One: Why are Medicare CQMs an option for the APP?

Laura says: “Dr. Mingle, I thought it’d be great if you started us with a kind of a primer of these new measures that CMS has introduced for ACOs. You’re always good at succinctly summarizing a lot of very complex information that comes out of those regulations. So maybe you could just walk us through how these measures are different than registry measures.”

Dr. Mingle: Well, thanks, Laura. That’s a great idea.

Medicare wants, ultimately, to be in all digital quality reporting, and they want one quality standard to apply to all groups of patients, not one for Medicare and one for everyone else.

Thus, they want to move ACOs to the all-patient, all-payer reporting to which MIPS submitters have been subject to since the onset of MIPS in 2017.

Medicare introduced the APM Performance Pathway (APP) in rulemaking for 2021 with plans to sunset the Web Interface and replace it with a set of three submitted measures, meant to be submitted by eCQMs or by MIPS CQMs on all patients of all payers. The APP measure set also has two administrative claims measures calculated on Medicare claims.

Medicare has been subject to intense lobbying from ACOs to postpone the sunset of the Web Interface. In 2024 rulemaking, Medicare introduced Medicare CQMS. They included the implied refusal to postpone the expected sunset of the Web Interface.

Medicare CQMs are intended to be temporary to allow ACOs more time to bridge the technology and process gap between the Web Interface and the more intense technical and methodological requirements to measure quality performance in all patients of all payers.

Question Two: What is a Medicare CQM?

Laura says: “Great summary Dr. Mingle. So, what exactly are Medicare CQMS?”

Dr. Mingle: Well, the specifications and methodology for Medicare CQMS are the same as MIPS CQMs.

But Medicare CQM measure specifications are only available for the submittable measures of the APP. You can’t use them in MIPS or any other quality reporting program.

The numerator and denominator specifications for each measure are identical to their MIPS CQM counterparts.

And you can use any method to collect and analyze data for MIPS CQMS and Medicare CQMS that you can use for eCQMs but the reverse doesn’t hold true. MIPS and Medicare CQMs have flexibility that you lose in eCQMs.

For eCQMs, you can’t use manual methods, and you can’t use non-certified data sources.

Now there’s only one important way that Medicare CQMS differs from MIPS CQMS: the eligible patient population.

Instead of all-patients, all-payers, as required by MIPS CQMs and eCQMs, it’s only patients that are covered by Medicare Part B and only those patients seen at least once in the performance year by a primary care provider in any of the TIN-practices participating in the ACO.

Question Three: How will Medicare CQMs help ACOs?

Laura says: “Maybe you could tell us about how Medicare CQMs will help a ACOs with their quality measure reporting?”

Dr. Mingle: Well, looking nationwide, about 12% of adults seeing a healthcare provider in any year are Medicare recipients.

Because of specialty, scope of care, and different dynamics, of those practices serving Medicare patients, about 30% of their patient population tends to be Medicare. In specific practices it can be higher or lower.

The main point is that a significantly smaller number than the all-patient, all-payer population is Medicare in most practices.

For most of the work we do for our clients at Mingle Health, if we are working with our preferred standard of electronic data, it doesn’t really matter if we are analyzing 1000 patients of all payers or 300 patients with Medicare Part B. It might take a few seconds longer to transfer the data and run the analytics, but it’s nearly the same effort to us.

But if you need to do some manual work to improve the accuracy of your reporting, Medicare CQMs makes that task significantly easier because of the lower patient counts.

Question Four: Can you mix collection types?

Laura asks: “Can you use the Medicare CQMS and the MIPS CQMS in the same quality submission for an ACO?”

Dr. Mingle: Yes, you can, Laura.

Your submission, at least for 2024, can be any combination of MIPS CQMs, Medicare CQMs and eCQMs.

They can even be duplicative. You could submit all three measures all three ways and Medicare will give you credit for the best score found in your redundant submissions.

Question Five: Medicare’s quarterly list for Medicare CQMs

Dr. Mingle says: “Now, Laura, Medicare intends to provide practices with a quarterly list of patients that contains every patient that they’ve seen who might qualify for inclusion in Medicare CQMs. In your work here at Mingle Health, are you using this list? Does it help to generate the submission? What are the are the pros and cons of that list?”

Laura: The list has been a great resource for a couple of our clients.

The challenge for the Medicare CQMs is identifying all the correct payers so that we can do the filtering on our end. ACOs can have thousands of different payers across that entire enterprise.

We start helping ACOs who want to report the Medicare CQMS by collecting all of that payer data and correctly organizing it by Medicare and non-Medicare. Once you’re doing that, you want to validate: Do we have the right population? Is this the right size of Medicare population that we should expect to report on?

The nice thing about the quarterly file that CMS provides is it helps us validate the size of these populations and in a couple of instances we’ve helped our clients understand that they were under reporting, sometimes significantly, the size of their Medicare population. It’s been helpful as a reference tool.

The claims data allows us to further validate that we can also report the all-payer, all-patient MIPS CQMs that are also available to ACOs. We can provide the opportunity to look at both options if they want to.

I know there’s some mention in the rules about using this list for Medicare CQMs as the actual denominator, and we tend to prefer not to do that for a variety of reasons.

One issue we would see with using the CMS file as a source for creating a denominator is that those files come very late. The final file isn’t available until February, so that’s very late to look at your fourth quarter data before a submission in March. But even throughout the year, those files are not available until the start of the next quarter, so using the claims files from CMS to construct a denominator for the Medicare CQMs is problematic and can cause issues.

But it’s a great resource for helping us validate that we’ve got the right size of populations.

Question Six: Can Medicare CQMs be submitted through an EHR?

Laura says: “Another question about Medicare CQMs that we’ve seen come from our clients is if they can be submitted like an eCQM, through the EHR, or do they need to be reported through different methods?”

Dr. Mingle: Well, it’s possible, Laura.

The EHR would have to be functioning as a qualified registry, not as a certified eCQM provider to submit the Medicare CQMs.

And they would still have the challenge of identifying patients and deduplicating patients across all practices and all EHRs in the ACO.

Different EHRs do not generally play well together, and ACOs usually have multiple EHRs and participating practices contained within them.

It would be more credible for your EHR to do Medicare CQMs for you if there’s only one instance of one EHR in your ACO.

But in general, an EHR vendor would face a significant problem to deduplicate and identify patients across all practices and identify those patients to the clinical data that populates the numerator for Medicare CQMs.

Question Seven: What should ACOs ask EHR vendors about supporting Medicare CQMs?

Laura says: “And what questions should ACOs be thinking about for their EHR vendors about how to support to these Medicare CQMs?”

Dr. Mingle: Well, a couple of things.

As you’re talking to your EHR about this, ask them if they’re qualified registry. If they’re not, they’re unable to support Medicare CQMs.

Ask them about how they will identify and deduplicate the patients across multiple practices. The answer must be a credible technique.

Next, ask them how they will normalize the clinical numerator data to generate metrics across all EHRs in your ACO.

Finally, ask them how they are going to deal with missing data. If there’s critical things that you have recorded but were not recorded in a way the EHR could find it, how will the EHR vendor deal with that?

In fact, these are questions you should be asking even if you’re expecting them to do an eCQM submission for you. Of course, they don’t have to be a qualified registry to do eCQM submissions, they just need to be ONC certified.

Question Eight: Are Medicare CQMs easier to report?

Laura says: “We talked a little bit earlier about this quarterly list that Medicare provides to help with the Medicare CQM reporting. So, does this list mean that it’s easy to report these Medicare CQMs?”

Dr. Mingle: I think as you said, the last list is a bit late and it’s not a trivial problem that it’s expected to be delivered in February with a submission deadline at the end of March. It’s a little late to comfortably use for your final full year submission.

And you also are facing the same problem that you’re facing with any source of denominator data. You need to confirm eligibility.

From our early experience, we can’t just take it for granted that Medicare is exactly right on the eligibility for each measure. We need to confirm that with service codes and ICD codes checked from wherever we get it, and we still must identify the patients to the practices where they were seen, and the clinical numerator data, which again is not a trivial matter.

The process is pretty much the same for Medicare’s list and where we usually get data, which is from your claims generated in the practice.

Using your claims gives us at least an extra month to two months to generate that final submission

And we’re doing it through the whole year, at whatever frequency you’d like to check up on your performance as you progress.

Question Nine: Data Completeness Requirements

Laura says: “For Medicare CQMs, do we need to report on 100% of that denominator?”

Dr. Mingle: No. Medicare reporting is subject to what they call a data completeness requirement.

Now typically for most electronic submissions, you get all the data from all your EHR, and you reach 100% data completeness.

But electronic submissions for an ACO are a different beast than a single location practice with a combined EHR.

There are some member practices that you’ll have trouble getting data from, and you’re allowed some wiggle room to make this process a little easier. Medicare’s requirement is 75% of the eligible patients need to be included in your submission.

Question Ten: Will Medicare CQMs give your ACO a better score?

Laura says: “For ACOs, I know many of them see Medicare CQMs as a way to optimize scores, especially in cases where manual chart abstraction is necessary. If I have more manual chart abstraction, especially for measure 134, or I have a huge population, I may not be able to get to the full population to report eCQMs but I could get to the smaller Medicare-only population. The main attraction is that manual chart review volumes can be much more manageable for the ACO, which can improve overall scores for their submission.”

Dr. Mingle: You’re right, Laura, and that’s an interesting observation.

I think it may be somewhat of a toss-up for what to expect because there’s counteracting events going on here.

It would be entirely true that if your score was based on the absolute value of the performance score, you’d do better. Anything that involves a manual data abstraction tends to score better than the electronic, simply because if you miss data, it’s going to reduce your score, not increase it. If it’s missing, it looks like you didn’t do it.

So, your raw numbers are going to be higher, but then you have to realize that ACOs aren’t scored on the raw numbers. They’re scored on a curve as a percentile rank.

If your competitors are highly functioning, you may end up lower in that list.

For eCQMs and MIPS CQMs, your comparison group is all practices in the United States submitting those measures for MIPS by the same collection method that you are using.

For Medicare CQMs, you have a much smaller comparison group. It’s restricted to ACOs. And I expect that the typical ACO will perform better in real terms on these measures than other practices, because ACOs are more focused on quality performance and put more effort and resources into improving quality.

Good quality performance is essential for collecting shared savings, so I expect them to perform at a higher level.

But Medicare is proposing in the 2025 Proposed Rule to establish flat benchmarks for Medicare CQMs until historical benchmarks are available in the third year of the collection method’s use. So, you’ll at least have an idea of your possible scores at any performance rate for the first two years of Medicare CQMs.

Question Eleven: How Mingle Health helps ACOs with Medicare CQMs

Laura says: “So in summary, how can Mingle Health help ACOs with Medicare CQMs?”

Dr. Mingle: Medicare CQMs are the same process as our usual MIPS CQM process. The only difference is restricting our eligible patient list to the Medicare Part B recipients who have seen a primary care provider in your ACO in the performance year.

In fact, if we get data to our preferred specs, we can toggle back and forth between Medicare CQMs and MIPS CQMs with just the flip of a filter.

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.