Accountable Care Organizations

Looming changes to quality reporting in the Medicare Shared Savings Program draw strong pushback from healthcare providers

May 18, 2021 7:56 pm
  • Healthcare provider associations are petitioning the Biden administration to slow recently finalized changes to the Medicare Shared Savings Program.
  • A key concern is the new requirement to report electronic clinical quality measures that involve burdensome data-aggregation steps among the various participants in an ACO.
  • Another problematic requirement is the expansion of quality measures to encompass all payers affiliated with an ACO.

CMS’s pending overhaul of quality reporting for accountable care organizations (ACOs) has generated a negative response, with healthcare provider organizations predicting a significant increase in administrative burden and no corresponding quality improvement.

The Medicare Shared Savings Program (MSSP) is undergoing major changes to its quality-related processes after CMS pushed through updates in the most recent final rule for the Medicare Physician Fee Schedule. The rule was finalized after a comment period in which many stakeholders expressed strong concerns about the proposed modifications.

Now, some of those same stakeholders hope a new administration will see their point of view and respond accordingly.

New requirements relating to EHR data

Starting in 2022, MSSP participants must report on three electronic clinical quality measures (eCQMs)/Merit-based Incentive Payment System (MIPS) CQMs:

  • Diabetes: Hemoglobin A1c poor control (>9%)
  • Preventive Care and Screening: Screening for depression and follow-up plan
  • Controlling High Blood Pressure

That requirement likely would lead to massive costs and increased burden without enhancing care quality, according to a letter from 11 leading provider associations to Xavier Becerra, secretary of the U.S. Department of Health and Human Services.

The letter notes that the MSSP has 477 participants in 2021, down from 561 in 2018. Changes that prove onerous and costly while adversely affecting the opportunity to share in savings could further diminish participation, the organizations wrote.

To share in savings starting in 2022, ACOs will have to collect the three new measures via their electronic health records (EHRs) unless they report MIPS CQMs through a qualified registry.

Because the organizations that comprise an ACO likely use distinct EHRs, ACOs face the prospect of paying additional vendor fees to aggregate data, according to a statement from the National Association of ACOs (NAACOS), one of the signatories of the letter

“In the middle of a global pandemic, it seems outrageous for CMS to require these changes that have questionable clinical benefit and cost hundreds of thousands of dollars per ACO,” Clif Gaus, ScD, president and CEO of NAACOS, said in the statement. “CMS is naive to think the state of EHRs today allow these quality data to be easily compiled.”

Among other changes, the 11 healthcare associations are asking Becerra to delay the mandatory reporting of the three new CQMs for at least three years.

CMS’s initial replies to stakeholder concerns

In the final rule, CMS wrote that one option for reporting the data would be to “combine the results from all the ACO participant TIN QRDA 3 files by adding numerators, denominators, etc. and create an aggregate QRDA 3 file (or other compliant file format) and submit as an ACO to CMS.”

Ensuring EHR vendor readiness for the changes is a priority, John Pilotte, director of the performance-based payment staff at CMS’s Center for Medicare, said in April at the NAACOS Spring 2021 Conference.

That likely will be difficult, the associations wrote in the letter to Becerra.

“While one might assume that EHR vendor systems with 2015 Certified Electronic Health Record Technology (CEHRT) would be able to easily report the most recent version of an eCQM for MIPS with minimal manual effort, that is not the case,” the letter states. “In addition, the CEHRT requirements do not standardize the capture and reporting of individual eCQM data elements across vendor systems, and ACOs will still need to tailor data extracts and uploads across systems and participating TINs.”

It remains to be seen what CMS does with such comments, but Pilotte said the responses are welcome.

“We appreciate the feedback. The more detailed it gets — the more implementation and operational issues that come to our attention — that’s helpful feedback that we can take back to look at what we need to assess and what gaps we need to address, and how can we move forward on this,” he said.

Apprehension over the requirement to report all-payer data

The 11 associations also are concerned because the new quality measures cover an ACO’s performance across payers rather than only for attributed patients.

“The new MSSP measures may be especially sensitive to differences in clinical complexity and social risk factors across patient populations,” the letter to Becerra states. “Yet, CMS has not articulated how the agency will account for these differences, which is especially problematic since the data will be collected on an all-payer basis. This policy gap means that ACOs serving sicker and more vulnerable patients may score more poorly,” with lower quality scores translating to less shared savings.

In the final rule, CMS defended the all-payer approach to ACO quality reporting as a means to nudge participants to improve care delivery for their entire population of patients. But such an approach could muddy the picture for specialists that participate in an ACO.

Patients “who receive care from a specialist participating with an ACO will be attributed as eligible for a measure denominator for a clinical service intervention that is outside of the typical scope and practice of that clinician,” the letter notes.

“Certain specialists may consider it clinically inappropriate for them to take steps to meet the primary care quality measure if the measure and its related care are outside of their professional focus. … This creates the potential that performance will not be met, and ACO quality scores would be negatively impacted.”

Possible issues with Stark Law and HIPAA

In a town hall session with CMS officials at the NAACOS conference, some attendees also wondered whether patient privacy issues could emerge if ACOs have to report data on non-attributed patients. The letter to Becerra echoes that concern, saying that as a result of the burden stemming from related compliance requirements, fewer individual providers may remain in the MSSP either because they leave on their own or because their ACO chooses to exclude them.

The “unintended consequence of reducing the breadth of providers engaged in a total cost of care model is troubling,” the letter states.

In the town hall, Pilotte downplayed privacy concerns.

“They’re aggregated measures that come out of the system, and we believe that ACOs should be able to access that information from their participant TINs and report that aggregated data out,” Pilotte said. “If there are specific issues or barriers around this, we’d appreciate hearing specific examples.”


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