CMS is proposing to change quality reporting standards in the Medicare Shared Savings Program and accountable care organizations are pushing back.
In the 2021 proposed physician fee schedule rule released Aug. 3, CMS proposed three main changes related to quality: a new mechanism for ACOs to report quality measures, a reduction in the Medicare Shared Savings Program's required measures and higher quality performance standards for ACO bonuses. ACOs took issue with these proposals, raising concerns that it's too much change during a time where there is already heightened stress and uncertainty from the COVID-19 pandemic.
"Given the magnitude of what they (CMS) are looking to do in terms of quality, it's really too much," said Allison Brennan, senior vice president of government affairs at the National Association of ACOs.
The proposed changes to quality reporting and measures are part of an effort by CMS to align the Medicare Shared Savings Program with the Quality Payment Program, which includes the Merit Based Incentive Payment System, in order to reduce burden.
"We believe that using a single methodology to measure quality performance under both the Shared Savings Program and MIPS would allow ACOs to better focus on increasing the value of healthcare, improving care and engaging patients," CMS said in the proposed rule.
Under the proposal, the number of quality measures ACOs report will decrease from 23 to six. CMS said it was difficult to "meaningfully distinguish quality performance" across ACOs with the current set of 23 measures. The six measures are all outcomes measures and include hemoglobin A1c control, controlling high blood pressure and 30-day all-cause unplanned readmission.
With such a reduction in measures, there are worries the Medicare Shared Savings program will lose its impact, said Dr. Robert Fields, chief medical officer of population health at Mount Sinai Health System in New York, which has a Medicare ACO with just under 50,000 Medicare beneficiaries.
"You can sometimes water down a program so much that it starts to really lose value," he said, adding he doesn't have an issue with the six measures listed but he's not sure "it's enough to (understand) preventive care."
While Tim Gronniger, CEO of Caravan Health, which operates 12 ACOs, isn't too concerned about the reduction of measures, he is worried that poor performance on one measure could tank any possibility of achieving savings.
CMS is proposing that in addition to less measures, if an ACO fails to achieve the minimum performance standard for any one of the six measures, the ACO fails in quality and is no longer eligible for savings. The quality performance standard will also increase from performing the measure at the 30th percentile of the benchmark to the 40th percentile.
Gronniger said that's concerning because there isn't much room for changes in performance for measures that have little variation such as the readmission measures. "You could see a half a point difference in improvement or reduction in performance making a gigantic difference," he said.
CMS said more stringent quality standards align with the maturity of the program. Now in its eighth year, the agency said "holding ACOs to a higher standard is in line with CMS' goals of incentivizing value-based care and driving the Medicare system to greater value and quality."
The agency also found 95% of ACOs would achieve quality performance at or above the 40th percentile for all the new quality categories using 2018 quality measure data.
Another proposed change is CMS sunsetting the CMS Web Interface, which ACOs use to report quality measures. ACOs would instead report quality measures through vendor platforms currently approved for MIPS.
CMS acknowledges the move away from the CMS Web Interface would be "a big change" for ACOs but the agency argues it will be less burdensome because there will be fewer measures to report and electronic-clinical quality measures are now included.
Brennan said it's too much for ACOs to adopt to at this time given the pandemic. A new reporting mechanism will require training of staff and workflow changes. "It's a very big undertaking," she said.
Fields added he's uncertain about the use of electronic clinical quality measures to report three of the measures: hemoglobin A1c control, screening for depression and controlling high blood pressure. He said in his experience with electronic clinical quality measures there is still work to be done by electronic medical record vendors. Some EMR vendors are better than others at searching medical records to fulfill measures, which can lead to errors in how clinicians are scored for their performance.
"There is some homework to do on the EMR industry side before that is actually going to work," Fields said.
ACOs are also concerned that clinicians participating in the Merit Based Incentive Payment System, or MIPS, can qualify for higher bonuses in performance year 2023 than advanced alternative payment models, which risk bearing ACOs are considered and receive a 5% bonus. CMS anticipates more clinicians will be involved in MIPs than in an advanced alternative payment model in 2021.
Brennan said this will deter clinicians from joining advanced alternative payment models at a time "when we need more emphasis on value-based care."
The comments to CMS proposals are due October 5.
