This episode of Ask Dr. Mingle features listener questions for Dr. Dan Mingle about the measure set for Digital Quality Measures (dQMs), scoring dynamics for MIPS Value Pathways vs. MIPS, and the 180 day Promoting Interoperability reporting period.

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Question One: Measure Set for Digital Quality Measures (dQMs)

Tony asks: “What measure set do digital quality measures use?”

Digital Quality Measures (dQMs) today is more of a concept than an established thing.

Medicare has provided a Digital Quality Measurement Strategic Roadmap.

There’s little if nothing in the rules at this point, except I would say for that there’s a dichotomy in the choices you see that are described as electronic Clinical Quality Measures (eCQMs) or MIPS CQMs.

There is a natural sorting there. Electronic Clinical Quality Measures are digital quality measures, and they’re only electronically specified. There is no other way to create them.

MIPS clinical quality measures are a mixture. They can be done digitally. They can also be done manually, and any data set that’s out there can contribute to MIPS CQMs.

2024 is an important year in that it’s the first time I’ve seen the concept of digital Quality Measures proposed in the rule set and that proposal relates to the APM Performance Pathway (APP). In the proposal, Medicare suggests dropping MIPS CQMs from the choices available for the APP, leaving only eCQMs and Medicare CQMS.

Medicare CQMs are a subcategory of MIPS CQMs that allow ACOs to report on a smaller patient population for their APP submission. Medicare CQMs are proposed as a temporary option to ease the transition from the Web Interface to the APP, but there’s no proposal for when they will disappear. Therefore, removing MIPS CQMs from the list implies that once Medicare CQMs are deemed to be no longer necessary, it will leave only eCQMs as an option to submit the APP measures.

The justification for this change is solely that this is part of Medicare’s move to Digital Quality Measures.

So, they’re defining dQMs in this proposed rule as only eCQMs.

That’s been in the strategy at least once before, and I commented against it, and I’ll do it again with this rule.

With eCQMs you get a lot of restrictions. It’s a very delicate system that’s all certified, all electronic, to go from documentation of care for your patients to a submission to Medicare or other stakeholders or insurers. And I think it’s a step away from the importance of quality reporting. I think we all should be measuring our quality, and we should all build as robust measurement systems as we can.

Ultimately, it’s good that those systems are digital. But to require that it all be certified and all be digital is restrictive, and I think it is a better measure today of the investment put into your measurement program, not so much a measure of the quality of care you’re providing. A lot of people with high quality care are not going to be able to show it if they are restricted to all electronic data sources, I don’t think we are as an industry ready for that. And I think when we are, it’ll be a functional thing that pushes us to be there. It shouldn’t be a rule.

The quality of a MIPS submission is determined by its correctness. And MIPS qualified registries are required to analyze correctly. It’s a step beyond certified. I’ve seen a lot of certified measurement systems that don’t work terribly well. The eCQM certification does a great job of saying “this is the path we followed to go from documentation to quality report”, but again, I think it measures the system and the investment into the system better than the quality of care.

So, I am not sure I answered your question.

I think that Digital Quality Measures should be eCQMs and MIPS CQMS. For eCQMs, they’re already electronic. And MIPS CQMs can do everything that an eCQM can do, can use all those data sources, plus others. To make MIPS CQMs pure digital quality measures we just eliminate some of the data sources that aren’t electronic.

If you agree with me, it would be a good year to put that comment in for Medicare before they go further down this path that I think is dysfunctional for you.

Question Two: Promoting Interoperability Reporting Period

Jason asks: “I’m trying to better understand Promoting Interoperability (PI). July 5th was the last day to begin reporting PI for 2024. If a group did not start this, does that mean they automatically lose 25% of their MIPS score? Is there any way to still get some of it?”

Great question, Jason.

You know, it really doesn’t matter when you start.

For your PI measurement project, it’s the minimum period during which the EHR is in place and the date range from which the data is drawn.

The system must be in place and the PI metrics drawn for at least 180 days. In the performance calendar year, anything less than 180 days yields zero points for PI. It doesn’t matter if the 180 days is the in the beginning, middle, or end of the year, as long as it’s 180 days.

For a couple of the measures that are a numerator and denominator, if you are going to have a better score with a particular portion of the year, it may be beneficial to choose something other than the whole year. I think in most cases you’re going to get similar, if not the same performance.

Question Three: MIPS Value Pathways (MVPs) Deep Dive

Jason asks: “Who are the ideal groups or prospects for MIPS Value Pathways, and why? Are there any particular specialties or group sizes better suited for MIPS Value Pathways? Are there cases where if a group were to report MVPs instead of MIPS, that decision alone could improve their score? And finally, are there any quantifiable ways to measure the impact of MVPs versus other methods?”

MVPs are ultimately going to affect all practices. Perhaps in 2028, the current proposed switch over date, or within a few years after that, Medicare intends to sunset traditional MIPS and fully implement MVPs. This means that all practices would be required to report MVPs rather than the traditional MIPS being reported now.

MVPs differ from traditional MIPS in that each MVP is a self-contained set of measures with a foundational set that includes some population health measure choices and a promoting interoperability measure set, which is the same for everyone. They also include measures that are selectable from a focused list of quality measures, and a focused list of practice improvement activities, all of which relate to the same clinical topic or specialty.

That is the main difference. Rather than choosing six measures from all of the available MIPS menu of measures, you’ll be offered a limited set that deals with that same clinical topic. They can be all drawn from eCQMs, all drawn from MIPS CQMs, all drawn from QCDR measures, or a mixture thereof.

Traditional MIPS is reported as either an individual or an entire group.

An individual will be able will be able to choose MVPs a small single specialty practice or any size single specialty practice will be able to choose a single MVP.

But multi-specialty groups are going to be most affected by this change to MVPs. MVPs will require multi-specialty groups to break up into multiple subgroups and make multiple MVP submissions. It’s not yet determined what the minimum size groups are going to be, or how eligibility is going to be determined.

Currently, MVPs are produced with a suggestion of specialties that they apply to. Every measure in an MVP has a set of denominators or eligibility specifications. There is a minimum number of 20 patients to make a valid submission. It is easy to imagine that Medicare may simply require that anyone that can generate a 20-patient minimum submission for four measures in an MVP can submit that MVP.

Medicare is now soliciting comments on this issue.

So, if you have ideas of how you like to see it apply, this is a good time in this 2025 rulemaking cycle to get your comments submitted to Medicare to help them help guide their thinking in that way.

I’m inclined to think that it shouldn’t so much be a specialty orientation as a service line orientation. You may need multiple specialties to optimally take care of a patient for joint replacement, you might need multiple specialties to optimally care for a patient with severe lung disease or cardiac surgery requirement or after a neurological event.

Medicare hasn’t determined exactly when they will make the switch. There’s certainly a proposed schedule in place in the 2024 Proposed Rules making the intention, or at least reaffirming the intention to make the switch around 2028, but also introducing some more certainty that MVPs will be fully implemented. There’s less certainty that the traditional MIPS will end in that year. And of course, in our experience in the past with programs like this that don’t have a legislated mandate, it would not be at all surprising if that were put off for some time.

The practices most affected are going to be multi-specialty groups. The practices least affected will be primary care providers and single specialty groups and the primary care practitioners within groups within multi-specialty practices, mostly because the group submission of measures is the most common method for practices to submit if they’re eligible for them, and most of them submit primary care-oriented measures to get every provider in the practice qualified for their MIPS adjustments. The primary care providers in single specialty groups or in multi-specialty groups will still be able to select the four measures from the group of six that they are all already in the habit of submitting.

It will affect mostly those multi-specialty practices in which they will no longer be leading the submission for the entire group but doing it just for themselves with other specialties or groups of providers breaking off into other MVPs. Now there may be some specialties that will no longer have access to measures that they have been successfully using, particularly when those measures are getting them qualified on what we call the Halo Effect, that is, it’s not their performance against the patients that drives their score, it’s someone else in their practice that does. Those will be the ones most affected by MVPs.

Now Jason, you ask also if there is a comparator.

We are in a honeymoon phase with MVPs in that you can choose to participate. And even for the 2024 year, you can choose to participate as a whole group, so just like whole groups have been qualifying or have been scoring MIPS based on a single submission of six primary care measures, a group in 2024 can still use an MVP submission and qualify the whole multi-specialty group on the measures of that single MVP, even if all the providers aren’t contributing to that measure or that measure set.

That will disappear eventually.

It’s supposed to disappear for the 2025 submission performance year if the current draft schedule stays in place.

Whether it’s good to submit MVPs or not remains a question. I don’t know any way to really predict that without doing both submissions in parallel and measuring your performance based on the set of MVPs that you are qualified for. There is a publication Medicare put out with the 2025 Proposed Rule that just focuses on MVPs. I would suggest that you download that document and read it.

They are soliciting comments on just about everything about MVPs and how you qualify and submit. They don’t know yet how they’re going to do it, but they’re concerned that large multi-specialty groups might have to break up into 20 or more MVPs, they want to figure out how to limit that liability.

And there’s still going to be some providers who don’t qualify for any measures. They don’t provide the care, and they don’t have the patients qualifying it in the denominators. How do they handle that? Is there a minimum size practice that will be required to do an MVP? If I’m the only doctor in a large multi-specialty group that is qualified for a certain MVP and there’s no others that I qualify for, will I be required to do that or can I just piggyback on someone else’s score?

Those are some of the questions being asked right now, and that you should consider. And if you have some comments, suggestions, or concerns, this is a good time to get your comments in.

I’m expecting a lot of thought on MVPs by Medicare in the next 12-month cycle. There’s a lot less known about MVPs, but the proposal for 2025 is to add six more MVPs and they now have what they think is a thorough set numerically for the majority of specialists out there, so that in itself is stimulating some more thought about what’s next and how to keep this ball rolling.

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